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West Virginia rates for HCPCS J0875

Injection, dalbavancin, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.49 / $11,481.54 / $19,952.62
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.14 / $15.14 / $16.98
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.79 / $15.49 / $85.11
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.49 / $66.07 / $66.07
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.49 / $15.49 / $15.49
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.14 / $15.49 / $20.42