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South Dakota rates for HCPCS J0642

Injection, levoleucovorin (Khapzory), 0.5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.42 / $1.42 / $1.42
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.12 / $1.42 / $1.42
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.20 / $1.42 / $1.50
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.60 / $1.89 / $3.07
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.12 / $1.25 / $1.42
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.35 / $1.41 / $2.08
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.35 / $1.69 / $4.88
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.55 / $1.55 / $1.55
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.42 / $1.58 / $1.58
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.12 / $1.12 / $1.12
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.12 / $1.12 / $1.12