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South Dakota rates for HCPCS Q0169

Promethazine Hydrochloride 12.5 Mg Oral Fda Approved Prescription Anti-Emetic For Use As A Complete Therapeutic Substitute For An Iv Anti-Emetic At The Time Of Chemotherapy Treatment Not To Exceed A 48 Hour Dosage Regimen (Special Coverage Instructions Apply)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.10 / $0.10 / $0.10
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.08 / $0.09 / $0.10
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.09 / $0.38 / $0.47
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.04 / $0.15 / $0.36
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.08 / $0.08 / $64.58
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.05 / $1.00 / $1.53
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.05 / $0.08 / $1.23
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.21 / $0.21 / $0.21
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.08 / $0.08 / $0.09
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.06 / $0.06 / $0.06
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.06 / $0.06 / $0.06