go back

Pennsylvania rates for HCPCS J0875

Injection, dalbavancin, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.71 / $41.05 / $14,198.63
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $15.77 / $40.32
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.40 / $16.94 / $8,639.91
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$16.20 / $16.20 / $16.20
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.73 / $15.61 / $15.61
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $15.61 / $15.61
Highmark BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$32.34 / $39.54 / $53.37
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.71 / $42.76 / $13,923.00
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $17.07 / $47.27
Priority Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.73 / $15.61 / $15.61
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $15.61 / $15.61
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.91 / $14.91 / $17.30
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$14.91 / $14.91 / $17.30
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $15.61 / $21.56