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Texas rates for HCPCS J0133

Injection, acyclovir, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$16.98 / $58.88 / $602.56
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.08 / $0.26 / $0.52
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.04 / $0.12 / $0.12
Baylor Scott & White
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.04 / $0.33 / $41.69
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.11 / $0.12 / $0.12
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.12
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.12 / $50.12 / $602.56
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.03 / $0.12 / $0.59
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.04 / $0.04 / $0.12
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.02 / $0.06 / $0.17
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.02 / $0.02 / $0.10
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.12