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Montana rates for HCPCS J0500

Injection, dicyclomine HCl, up to 20 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$86.86 / $156.94 / $196.98
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.47 / $14.13 / $87.95
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$72.88 / $77,999.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.68 / $14.68 / $120.13
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.36 / $11.36 / $14.68
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.68 / $14.68 / $120.13
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.36 / $12.33 / $19.05
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.36 / $11.36 / $11.36