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Utah rates for HCPCS J0875

Injection, dalbavancin, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$18.20 / $18.20 / $18.20
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.14 / $15.14 / $18.20
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$18.20 / $22.39 / $23.44
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $15.49
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$23.99 / $30.20 / $54.95
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.14 / $15.49 / $18.62
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$14.13 / $15.49 / $18.62
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $15.49