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South Dakota rates for HCPCS 50080

Percutaneous nephrolithotomy or pyelolithotomy, lithotripsy, stone extraction, antegrade ureteroscopy, antegrade stent placement and nephrostomy tube placement, when performed, including imaging guidance; simple (eg, stone[s] up to 2 cm in single location of kidney or renal pelvis, nonbranching stones)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$659.97 / $659.97 / $659.97
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$850.42 / $1,208.33 / $2,326.65
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,500.00 / $2,271.67 / $8,958.90
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$967.97 / $1,286.35 / $1,472.39
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,500.00 / $4,500.00 / $4,500.00