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Montana rates for HCPCS J0642

Injection, levoleucovorin (Khapzory), 0.5 mg

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.36 / $1.36 / $5.24
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.34 / $1.34 / $5.74
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.34 / $1.42 / $1.42
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.34 / $1.34 / $5.74
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.42 / $1.54 / $2.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.42 / $1.42 / $1.42