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South Dakota rates for HCPCS 90697

Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenzae type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for intramuscular use

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$164.60 / $164.60 / $164.60
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$157.00 / $164.60 / $207.39
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$150.75 / $152.26 / $188.44
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$187.04 / $278.17 / $451.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$172.37 / $172.37 / $172.37
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$176.06 / $176.06 / $176.06
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$158.97 / $158.97 / $158.97
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$172.37 / $172.37 / $177.07
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$156.62 / $156.62 / $156.62
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$156.62 / $156.62 / $156.62