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Pennsylvania rates for HCPCS J1451

Injection, fomepizole, 15 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.89 / $19.34 / $2,296.12
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.89 / $12.89 / $12.89
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$10.69 / $12.58 / $8,639.91
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.58 / $12.58 / $12.58
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.89 / $12.89 / $12.89
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.89 / $12.89 / $12.89
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.89 / $19.34 / $35.96
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.89 / $12.89 / $25.65
Priority Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.89 / $12.89 / $12.89
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.89 / $12.89 / $12.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.43 / $12.43 / $17.17