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South Dakota rates for HCPCS J0133

Injection, acyclovir, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $1.00 / $1.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.11 / $0.11 / $0.14
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.04 / $0.06 / $0.14
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.03 / $0.03 / $0.04
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.03 / $0.03 / $0.03
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.13
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.05 / $0.12 / $0.13
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.04 / $0.04 / $0.04