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South Dakota rates for HCPCS J0875

Injection, dalbavancin, 5 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.61 / $15.61 / $15.61
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $15.61 / $18.82
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.86 / $15.86 / $19.82
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$18.72 / $24.54 / $42.61
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.55 / $15.55 / $17.11
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$17.48 / $18.72 / $27.30
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17.39 / $17.96 / $23.40
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17.09 / $17.09 / $17.09
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.61 / $15.61 / $17.17
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.55 / $15.55 / $15.55
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.55 / $15.55 / $15.55