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Washington rates for HCPCS J0133

Injection, acyclovir, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$7.59 / $66.07 / $245.47
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.11 / $0.11 / $0.12
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.15
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$64.57 / $64.57 / $75.86
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.03 / $0.04 / $0.08
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.04 / $0.04 / $0.14
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.03 / $0.04 / $0.04
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.12
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.12
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.12
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.16