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Montana rates for HCPCS J1190

Injection Dexrazoxane Hydrochloride Per 250 Mg (Special Coverage Instructions Apply. See Mcm: 2049)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6,656.27 / $6,656.27 / $6,656.27
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$38.83 / $63.06 / $523.82
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$758.26 / $77,999.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$92.41 / $92.41 / $624.86
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.06 / $63.06 / $92.41
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$92.41 / $92.41 / $624.86
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.06 / $68.41 / $105.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.06 / $63.06 / $63.06