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South Dakota rates for HCPCS L8604

Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,374.87 / $2,374.87 / $2,374.87
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$95.00 / $2,374.87 / $2,374.87
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$135.85 / $260.30 / $4,013.53
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,371.10 / $3,371.10 / $3,371.10