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Indiana rates for HCPCS J0875

Injection, dalbavancin, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.85 / $43.65 / $12,882.50
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.14 / $15.14 / $15.85
Ambetter
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $15.49
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$18.20 / $23.44 / $34.67
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $30.20
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.49 / $23.44 / $30.90
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.49 / $15.49 / $15.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $42.66
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.49 / $15.49 / $30.90
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $19.50