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South Dakota rates for HCPCS B4161

Enternal Formula For Pediatrics Hydrolyzed/Amino Acids And Peptide Chain

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.13 / $1.13 / $1.13
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.13 / $1.13 / $3.01
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.25 / $2.25 / $2.81
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.63 / $3.24 / $5.09
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3.01 / $3.01 / $3.01
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3.01 / $3.01 / $3.18
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.54 / $2.54 / $2.54
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.88 / $2.88 / $2.88
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.65 / $2.65 / $2.65