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Texas rates for HCPCS J0875

Injection, dalbavancin, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.14 / $30.90 / $3,090.30
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.14 / $15.14 / $19.50
Ambetter
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $15.49
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.49 / $38.02 / $72.44
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$18.20 / $18.20 / $18.20
Baylor Scott & White
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.49 / $35.48 / $4,677.35
Christus
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,548.13 / $3,548.13 / $3,548.13
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.79 / $15.49 / $15.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $15.49
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$85.11 / $100.00 / $100.00
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.49 / $19.50 / $3,090.30
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.14 / $15.14 / $16.98
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $15.49
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.14 / $22.39 / $47.86
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.14 / $15.14 / $16.98
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.49 / $15.49 / $15.49
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $15.49