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South Dakota rates for HCPCS 33963

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age (includes fluoroscopic guidance, when performed)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$467.74 / $467.74 / $4,365.16
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$407.38 / $512.86 / $549.54
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$977.24 / $977.24 / $1,230.27
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$616.60 / $724.44 / $1,318.26
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$416.87 / $794.33 / $3,311.31
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,000.00 / $1,000.00 / $1,047.13
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$616.60 / $831.76 / $891.25
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,995.26 / $1,995.26 / $1,995.26
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$562.34 / $912.01 / $1,230.27
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$912.01 / $1,071.52 / $1,122.02