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Wisconsin 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 / $1,784.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$800.00 / $800.00 / $1,000.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$301.04 / $850.00 / $850.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$212.00 / $523.59 / $748.44
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$212.00 / $226.34 / $274.69
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$800.00 / $800.00 / $800.00
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$490.08 / $490.08 / $490.08
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$800.00 / $800.00 / $800.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$212.00 / $212.00 / $339.20
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $55.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$800.00 / $800.00 / $800.00
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$490.08 / $490.08 / $490.08
Quartz
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 / $339.20