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New Hampshire 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
$850.00 / $850.00 / $1,045.92
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$850.00 / $850.00 / $850.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$212.00 / $212.00 / $212.00
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
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$212.00 / $212.00 / $424.00
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$850.00 / $935.00 / $1,190.00