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South Dakota rates for HCPCS B4162

Enternal Formula For Pediatrics Special Metabolic Needs For Inherited Disease

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.73 / $0.73 / $0.73
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.73 / $0.73 / $2.11
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.12 / $1.12 / $1.41
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.04 / $3.02 / $3.88
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.39 / $2.39 / $2.39
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.39 / $2.39 / $9.73
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.36 / $5.36 / $5.36
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$8.10 / $8.10 / $8.10