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Utah rates for HCPCS J0133

Injection, acyclovir, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$30.90 / $64.57 / $64.57
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.04 / $0.08 / $0.08
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.12
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.02 / $0.02 / $0.06
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.04 / $0.04 / $0.14
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.12