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North Dakota 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 / $1,800.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$800.00 / $1,000.00 / $1,000.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$219.75 / $219.75 / $274.69
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$800.00 / $1,000.00 / $1,360.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$212.00 / $212.00 / $230.24
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$180.20 / $212.00 / $262.88