Products billed under this code include Dalbavacin HCl, Dalbavancin, Dalvance, Dalvavancin.
Payment limit per 5 MG, by effective quarter, 1Q21 to 4Q26. Gaps mean the code was not in that quarter’s file, or CMS gave no payment limit.From the 4Q26 NDC–HCPCS crosswalk. “Limit / pkg” is the 4Q26 payment limit times the billing units in one package.
| Product | Labeler | NDC | Units / pkg | Limit / pkg |
|---|---|---|---|---|
| Dalbavacin HCl | Teva Pharmaceuticals USA, Inc. | 00480-3325-01 | 100 | $943.90 |
| Dalbavancin | Meitheal Pharmaceuticals Inc. | 71288-0034-50 | 100 | $943.90 |
| Dalbavancin | Long Grove Pharmaceuticals, LLC | 81298-2390-01 | 100 | $943.90 |
| Dalvance | Allergan, Inc. | 57970-0100-01 | 100 | $943.90 |
| Dalvavancin | FreseniUS Kabi USA, LLC | 65219-0120-12 | 100 | $943.90 |
| Quarter | Payment limit | Change | Billing unit | Description | Source file |
|---|---|---|---|---|---|
| 4Q26 | $9.439 | −$1.854 | 5 MG | Injection, dalbavancin | v1, posted September 17, 2026 |
| 3Q26 | $11.293 | −$3.71 | 5 MG | Injection, dalbavancin | v1, posted September 15, 2026 |
| 2Q26 | $15.003 | −$0.586 | 5 MG | Injection, dalbavancin | v1, posted September 15, 2026 |
| 1Q26 | $15.589 | −$0.024 | 5 MG | Injection, dalbavancin | v1, posted September 15, 2026 |
| 4Q25 | $15.613 | +$0.063 | 5 MG | Injection, dalbavancin | v1, posted September 8, 2026 |
| 3Q25 | $15.55 | −$0.017 | 5 MG | Injection, dalbavancin | v1, posted March 10, 2026 |
| 2Q25 | $15.567 | −$0.033 | 5 MG | Injection, dalbavancin | v1, posted March 10, 2026 |
| 1Q25 | $15.60 | −$0.012 | 5 MG | Injection, dalbavancin | v1, posted December 19, 2025 |
| 4Q24 | $15.612 | −$0.177 | 5 MG | Injection, dalbavancin | v1, posted June 11, 2025 |
| 3Q24 | $15.789 | +$0.667 | 5 MG | Injection, dalbavancin | v1, posted June 11, 2025 |
| 2Q24 | $15.122 | −$0.171 | 5 MG | Injection, dalbavancin | v1, posted March 11, 2025 |
| 1Q24 | $15.293 | +$0.079 | 5 MG | Injection, dalbavancin | v1, posted December 19, 2024 |
| 4Q23 | $15.214 | +$0.511 | 5 MG | Injection, dalbavancin | v1, posted October 10, 2024 |
| 3Q23 | $14.703 | −$0.612 | 5 MG | Injection, dalbavancin | v1, posted June 5, 2024 |
| 2Q23 | $15.315 | +$0.406 | 5 MG | Injection, dalbavancin | v1, posted February 23, 2024 |
| 1Q23 | $14.909 | −$0.253 | 5 MG | Injection, dalbavancin | v1, posted December 6, 2023 |
| 4Q22 | $15.162 | +$0.25 | 5 MG | Injection, dalbavancin | v1, posted June 22, 2023 |
| 3Q22 | $14.912 | +$0.44 | 5 MG | Injection, dalbavancin | v1, posted June 9, 2023 |
| 2Q22 | $14.472 | −$0.347 | 5 MG | Injection, dalbavancin | v1, posted December 14, 2022 |
| 1Q22 | $14.819 | −$1.07 | 5 MG | Injection, dalbavancin | v1, posted June 8, 2022 |
| 4Q21 | $15.889 | +$0.092 | 5 MG | Injection, dalbavancin | v1, posted June 2, 2022 |
| 3Q21 | $15.797 | +$0.273 | 5 MG | Injection, dalbavancin | v1, posted June 2, 2022 |
| 2Q21 | $15.524 | +$0.131 | 5 MG | Injection, dalbavancin | v1, posted March 1, 2022 |
| 1Q21 | $15.393 | – | 5 MG | Injection, dalbavancin | v1, posted December 10, 2021 |
“Change” is the difference from the previous quarter, shown only when both quarters have a payment limit and the billing unit is the same. “vs. last quarter” and “vs. a year ago” follow the same rule.
