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Montana rates for HCPCS J7204

Injection, Factor VIII, antihemophilic factor (recombinant), (Esperoct), glycopegylated-exei, per IU

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.00 / $2.00 / $5.75
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.45 / $2.45 / $2.45
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.24 / $2.24 / $2.45
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.24 / $2.29 / $6.31
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.24 / $2.29 / $6.31
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.45 / $2.45 / $2.45
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.24 / $3.16 / $85.11
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.24 / $2.24 / $2.24