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Wisconsin rates for HCPCS J0295

Injection, ampicillin sodium/sulbactam sodium, per 1.5 g

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3.98 / $72.44 / $169.82
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $1.00 / $2.29
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.66 / $1.66 / $1.66
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.32 / $1.32 / $1.70
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.95 / $1.95 / $2.04
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.32 / $4.17 / $7.24
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.35 / $1.70 / $2.45
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.38 / $1.38 / $2.88
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.09 / $2.75 / $3.24
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.48 / $21.88 / $43.65
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.48 / $1.48 / $2.75
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.32 / $64.57 / $85.11
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.32 / $1.45 / $4.68
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.32 / $1.32 / $100.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.32 / $1.32 / $1.32
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.82 / $1.82 / $3.24
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.58 / $1.58 / $1.58
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.32 / $1.32 / $2.14