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Wisconsin rates for HCPCS J0476

Injection Baclofen 50 Mcg For Intrathecal Trial (Special Coverage Instructions Apply. See Mcm: 2049)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$51.45 / $131.04 / $154.36
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.95 / $51.45 / $134.16
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$62.44 / $62.44 / $62.44
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.95 / $49.95 / $67.20
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$68.39 / $68.39 / $79.92
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$49.95 / $94.44 / $135.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$54.83 / $58.39 / $68.53
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$40.74 / $67.20 / $109.78
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.70 / $99.90 / $100.80
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$40.74 / $67.20 / $148.26
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$67.20 / $67.20 / $99.90
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.82 / $65.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$40.74 / $67.20 / $109.78
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.70 / $99.90 / $100.80
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.95 / $64.40 / $136.16
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$273.30 / $273.30 / $273.30
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.95 / $49.95 / $49.95
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$55.44 / $70.13 / $83.32
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.95 / $49.95 / $69.12