go back

South Dakota rates for HCPCS J0295

Injection, ampicillin sodium/sulbactam sodium, per 1.5 g

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.39 / $57.60 / $244.72
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.39 / $1.40 / $1.80
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.61 / $1.61 / $2.02
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.97 / $2.52 / $4.57
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.39 / $1.49 / $1.64
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.79 / $1.97 / $4.44
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.87 / $2.46 / $4.44
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.52 / $1.52 / $1.52
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.39 / $1.39 / $1.53
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.49 / $1.49 / $1.49
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.49 / $1.49 / $1.49