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Wisconsin rates for HCPCS J0875

Injection, dalbavancin, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$16.02 / $31.10 / $15,052.44
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $16.07 / $40.32
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$19.51 / $28.88 / $34.81
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $15.61 / $19.82
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$21.37 / $21.37 / $24.98
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.61 / $37.88 / $54.15
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.86 / $23.85 / $27.10
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.59 / $15.55 / $34.21
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.33 / $31.22 / $31.22
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.82 / $15.55 / $34.21
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.55 / $15.55 / $31.22
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.57 / $65.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.59 / $15.55 / $34.21
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.33 / $31.22 / $31.22
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $24.13 / $48.00
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$85.00 / $85.00 / $85.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $15.61 / $15.61
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$16.94 / $21.92 / $23.20
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $15.61 / $23.42