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Montana rates for HCPCS J0133

Injection, acyclovir, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$56.23 / $56.23 / $147.91
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.13 / $46,773.51 / $95,499.26
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.04 / $0.04 / $0.20
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.04 / $0.12 / $0.12
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.05 / $0.06 / $0.16
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.05 / $0.06 / $0.16
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.04 / $0.04 / $0.20
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.02 / $79.43 / $85.11
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.12