go back

Maine rates for HCPCS J0875

Injection, dalbavancin, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$16.23 / $39.03 / $6,288.71
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$16.23 / $18.82 / $18.82
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.11 / $18.96 / $49.47
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $15.61 / $15.61
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.61 / $15.61 / $15.61
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $15.61 / $15.61
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $15.61 / $18.89
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$36.22 / $36.22 / $6,288.71
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$16.23 / $17.95 / $39.03
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$14.35 / $15.61 / $27.32