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Montana rates for HCPCS Q5114

Injection, Trastuzumab-dkst, biosimilar, (Ogivri), 10 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15,731.85 / $15,731.85 / $15,731.85
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.29 / $40.70 / $3,211.38
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$47,000.00 / $77,999.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$53.45 / $53.45 / $53.45
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.29 / $40.29 / $53.45
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$40.29 / $48.75 / $64.80
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$43.71 / $53.45 / $67.70
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.29 / $40.29 / $40.29