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Montana rates for HCPCS J1451

Injection, fomepizole, 15 mg

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.58 / $12.58 / $12.58
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.04 / $11.04 / $24.25
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.04 / $12.89 / $12.89
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.04 / $11.04 / $24.25
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$7.36 / $11.32 / $14.92
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.43 / $12.43 / $12.43