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Pennsylvania rates for HCPCS J0133

Injection, acyclovir, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5.13 / $16.60 / $251.19
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.11 / $0.13 / $5,011.87
Capital Blue Cross
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
Geisinger
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.12
Geisinger
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.18 / $0.21 / $0.21
Highmark BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.13 / $0.54 / $4.47
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5.13 / $20.42 / $758.58
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.03 / $0.05 / $0.11
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.03 / $0.05 / $0.11
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.17