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Alaska rates for HCPCS J0875

Injection, dalbavancin, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$102.33 / $15,488.17 / $15,488.17
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.14 / $15.49 / $28.84
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $15.49
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.49 / $15.49 / $18.62
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $50.12
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.49 / $30.20 / $46.77
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $15.49
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$28.84 / $28.84 / $41.69
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.14 / $16.98 / $60.26
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $23.44 / $31.62