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South Dakota rates for HCPCS 50575

Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, incision of ureteral pelvic junction and insertion of endopyelotomy stent)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$663.34 / $663.34 / $663.34
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$596.76 / $663.34 / $2,057.48
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,536.37 / $1,562.87 / $1,953.59
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$853.37 / $1,121.04 / $1,921.90
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$851.26 / $1,418.76 / $5,240.88
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,268.00 / $1,856.12 / $4,555.17
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,208.00 / $1,536.37 / $1,867.54
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$894.35 / $1,192.31 / $1,365.61
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
$933.26 / $1,865.63 / $1,982.88
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,354.70 / $1,593.80 / $1,657.60