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Wisconsin rates for HCPCS J0875

Injection, dalbavancin, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$16.22 / $30.90 / $18,197.01
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.14 / $15.14 / $26.92
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$19.50 / $19.50 / $34.67
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $19.95
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.49 / $32.36 / $56.23
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.85 / $19.95 / $28.84
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.59 / $15.49 / $33.88
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.44 / $30.90 / $30.90
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.79 / $15.49 / $33.88
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $25.12
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$64.57 / $64.57 / $85.11
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $16.98 / $46.77
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.49 / $15.49 / $85.11
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $15.49 / $15.49
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$16.98 / $20.42 / $25.12
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 / $21.38