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South Dakota rates for HCPCS 21077

Impression & Preparation Orbital Prosthesis

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,736.70 / $1,736.70 / $2,139.32
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,459.53 / $1,800.21 / $5,098.20
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,581.91 / $4,926.39 / $6,158.79
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,466.61 / $3,578.90 / $5,639.16
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,590.58 / $5,453.37 / $15,904.32
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,987.39 / $4,585.28 / $5,575.68
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,823.54 / $4,621.64 / $5,579.01
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,493.92 / $3,420.16 / $4,308.04
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,500.00 / $4,500.00 / $4,500.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,352.78 / $4,041.23 / $6,286.36
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,392.90 / $4,151.39 / $5,087.30