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Washington 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
$0.50 / $1.09 / $1.48
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.45 / $0.50 / $0.94
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.45 / $0.56 / $100.00
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.45 / $0.51 / $1.02
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.43 / $0.43 / $1.04
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.45 / $0.45 / $0.56
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.45 / $0.66 / $1.35
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.56 / $0.85 / $0.85
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.46 / $0.54 / $1.02
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.45 / $0.45 / $0.45
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.45 / $0.45 / $0.45
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.52 / $0.52 / $0.52
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.45 / $0.45 / $0.54