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Montana rates for HCPCS Q5108

Injection, pegfilgrastim-jmdb (Fulphila), biosimilar, 0.5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,993.30 / $5,959.00 / $7,052.11
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.12 / $100.12 / $3,816.85
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64,999.99 / $81,499.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$128.87 / $128.87 / $128.87
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$99.13 / $99.13 / $128.87
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$128.87 / $128.87 / $128.87
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$99.13 / $107.55 / $162.65
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$99.13 / $99.13 / $99.13