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Maine rates for HCPCS J1165

Injection Phenytoin Sodium Per 50 Mg (Special Coverage Instructions Apply. See Mcm: 2049)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.04 / $1.04 / $1.12
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.47 / $0.80 / $0.80
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.39 / $1.39 / $1.39
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.45 / $0.45 / $0.45
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.45 / $0.45 / $0.45
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.45 / $0.45 / $0.45
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.45 / $0.45 / $0.54
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.04 / $1.04 / $1.12
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.47 / $0.80 / $1.12
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.45 / $0.45 / $0.79