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Texas rates for HCPCS J1451

Injection, fomepizole, 15 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.40 / $21.60 / $31.10
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.89 / $14.76 / $18.00
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$9.53 / $25.82 / $51.64
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
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.00 / $100.00 / $100.00
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$7.56 / $15.16 / $17.77
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6.42 / $11.37 / $12.31
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$7.45 / $12.89 / $20.59
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10.19 / $12.89 / $12.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.43 / $12.43 / $12.43
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.43 / $12.43 / $16.78