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South Dakota rates for HCPCS B4153

Enteral Formula Nutritionally Complete Hydrolyzed Proteins (Amino Accis And Ing Tube 100 Calories = 1 Unit (Special Coverage Instructions Apply. See Cim: 65-10 And Mcm: 2130

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.67 / $1.67 / $1.67
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.67 / $1.67 / $2.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.88 / $1.89 / $2.34
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.31 / $2.86 / $3.38
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.57 / $1.57 / $2.75
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.83 / $2.25 / $2.62
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.10 / $2.62 / $4.25
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.49 / $1.72 / $2.06
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.53 / $1.53 / $2.75
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.04 / $2.04 / $2.04