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Maryland rates for HCPCS J0875

Injection, dalbavancin, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.55 / $7,880.33 / $12,781.52
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $15.61 / $20.84
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.55 / $15.55 / $15.61
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $15.61 / $19.88
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $15.61 / $19.22
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $15.61 / $21.35
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.60 / $15.60 / $15.60