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South Dakota rates for HCPCS J1451

Injection, fomepizole, 15 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.16 / $15.16 / $15.16
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.58 / $15.16 / $15.16
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6.75 / $8.44 / $8.44
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$8.15 / $17.87 / $37.36
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6.79 / $12.43 / $13.67
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$8.15 / $9.24 / $12.90
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$7.70 / $11.96 / $18.01
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.89 / $12.89 / $12.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.43 / $12.43 / $13.67
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.43 / $12.43 / $12.43
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.43 / $12.43 / $12.43