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Idaho rates for HCPCS J1452

Injection Fomivirsen Sodium Intraocular 1.65 Mg (Special Coverage Instructions Apply. See Mcm: 2049.3)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,000.00 / $1,000.00 / $1,000.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$800.00 / $850.00 / $1,000.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$212.00 / $212.00 / $212.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$212.00 / $212.00 / $212.00
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$850.00 / $911.60 / $1,229.80
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$78.00 / $78.00 / $78.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$212.00 / $212.00 / $296.80