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Montana rates for HCPCS J1572

Injection Immune Globulin (Flebogamma) Intravenous Non-Lyophilized (E.G. Liquid) 500mg

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$52.73 / $52.73 / $105.80
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$56.15 / $59.94 / $76.73
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$54.00 / $54.00 / $59.94
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$56.15 / $59.94 / $76.73
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$54.00 / $59.94 / $63.53
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$52.94 / $52.94 / $52.94