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Wisconsin rates for HCPCS J0133

Injection, acyclovir, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$114.82 / $131.83 / $691.83
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $1.00 / $1.00
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.15 / $0.15 / $0.15
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.15
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.05 / $0.10 / $0.13
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.11 / $0.14 / $0.23
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.04 / $0.04 / $0.71
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.06 / $0.08 / $0.26
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.03 / $0.03 / $2.34
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.03 / $0.03 / $0.08
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $64.57 / $85.11
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.10 / $0.12 / $1.00
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.12 / $0.12 / $100.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.12
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.03 / $0.03 / $0.03
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.04 / $0.04 / $0.04
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.16