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Wisconsin rates for HCPCS Q5108

Injection Pegfilgrastim-Jmdb (Fulphila) Biosimilar 0.5 Mg (Desc Revised 04/01/23)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$102.10 / $155.57 / $311.13
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$99.12 / $102.10 / $933.57
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$183.39 / $213.13 / $221.06
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$99.13 / $99.13 / $153.65
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$146.71 / $158.61 / $181.69
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$99.13 / $126.24 / $377.04
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$115.01 / $191.11 / $217.18
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$99.13 / $103.71 / $329.21
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$103.71 / $103.71 / $372.90
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$103.71 / $115.45 / $152.56
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$65.00 / $99.13 / $112.90
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$99.13 / $103.71 / $329.21
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$99.13 / $155.22 / $425.70
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$99.13 / $99.13 / $1,345.20
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$99.13 / $99.13 / $99.13
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$139.18 / $139.18 / $447.94
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$99.13 / $110.35 / $145.83