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South Dakota rates for HCPCS 21077

Impression and custom preparation; orbital prosthesis

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,737.80 / $1,862.09 / $2,137.96
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,584.89 / $2,137.96 / $3,801.89
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,311.31 / $5,011.87 / $6,309.57
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,454.71 / $3,467.37 / $5,623.41
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,187.76 / $5,011.87 / $15,848.93
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,890.45 / $4,570.88 / $5,495.41
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,890.45 / $4,570.88 / $5,623.41
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,570.40 / $3,548.13 / $4,365.16
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,466.84 / $4,466.84 / $4,466.84
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,290.87 / $3,801.89 / $6,309.57
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,388.44 / $4,168.69 / $5,128.61