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Maine rates for HCPCS J0133

Injection, acyclovir, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$91.20 / $125.89 / $269.15
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.37 / $0.37 / $0.37
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.12
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.12
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.12
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.02 / $0.02 / $0.12
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$39.81 / $91.20 / $269.15
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.10 / $0.12 / $0.18