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Wisconsin rates for HCPCS J0500

Injection Dicyclomine Hcl Up To 20 Mg (Special Coverage Instructions Apply. See Mcm: 2049)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.70 / $46.70 / $149.22
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.36 / $11.70 / $87.95
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.20 / $14.20 / $14.20
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.36 / $11.36 / $14.42
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.55 / $15.55 / $18.18
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.36 / $38.51 / $55.05
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$13.09 / $38.93 / $44.24
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.36 / $11.68 / $63.92
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$9.61 / $22.72 / $22.72
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.68 / $11.68 / $117.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.68 / $11.68 / $22.72
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.86 / $65.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.36 / $11.68 / $63.92
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$9.61 / $22.72 / $22.72
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.36 / $17.69 / $52.24
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.36 / $11.36 / $11.36
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.95 / $15.95 / $110.16
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.36 / $11.36 / $17.04