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South Dakota rates for HCPCS A4402

Lubricant Per Ounce (Special Coverage Instructions Apply. See Mcm: 2130)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.42 / $1.42 / $1.42
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.62 / $0.66 / $1.87
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.72 / $1.34 / $2.45
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.63 / $2.63 / $3.28
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.12 / $2.52 / $80.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.89 / $1.36 / $2.35
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.04 / $2.39 / $3.22
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.92 / $2.39 / $4.51
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.87 / $2.18 / $2.59
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.74 / $1.07 / $1.86
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.00 / $2.00 / $2.00