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South Dakota rates for HCPCS J0120

Injection Tetracycline Up To 250 Mg (Special Coverage Instructions Apply. See Mcm: 2049)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$16.64 / $16.64 / $16.64
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$13.81 / $16.64 / $16.64
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10.13 / $10.13 / $12.66
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$19.03 / $22.40 / $41.05
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$8.63 / $8.63 / $8.63