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Michigan 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
$800.00 / $800.00 / $2,496.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$800.00 / $800.00 / $800.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$212.00 / $212.00 / $850.00
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$207.84 / $1,400.00 / $2,496.00
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$207.84 / $249.40 / $800.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $30.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$212.00 / $212.00 / $224.93