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South Dakota rates for HCPCS J1120

Injection, acetazolamide sodium, up to 500 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$19.84 / $19.84 / $19.84
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$19.84 / $19.84 / $22.04
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$19.43 / $19.84 / $24.28
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$24.64 / $29.12 / $47.64
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17.23 / $17.23 / $19.84
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$20.67 / $25.94 / $30.62
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$20.67 / $26.26 / $32.43
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21.72 / $21.72 / $21.72
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$19.84 / $19.84 / $28.54
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$17.23 / $17.23 / $17.23
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17.23 / $17.23 / $17.23