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Montana rates for HCPCS J0875

Injection, dalbavancin, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.14 / $15.85 / $42.66
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$18.20 / $40.74 / $95,499.26
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$17.78 / $17.78 / $45.71
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $17.78
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.14 / $15.85 / $46.77
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.14 / $15.85 / $46.77
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$17.78 / $17.78 / $45.71
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.14 / $21.88 / $85.11
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $15.49