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Wisconsin 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
$0.47 / $1.29 / $1.52
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.45 / $0.47 / $1.31
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.56 / $0.56 / $0.56
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.45 / $0.45 / $0.66
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.62 / $0.62 / $0.72
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.45 / $1.07 / $1.53
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.53 / $0.98 / $1.11
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.45 / $0.66 / $0.99
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.26 / $0.90 / $0.99
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.66 / $0.66 / $1.42
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.66 / $0.66 / $0.99
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $65.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.45 / $0.66 / $0.99
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.26 / $0.90 / $0.99
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.45 / $0.52 / $1.04
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.45 / $0.45 / $0.45
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.63 / $0.63 / $1.30
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.45 / $0.45 / $0.72