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South Dakota rates for HCPCS 50722

Ureterolysis For Ovarian Vein Syndrome

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$961.72 / $961.72 / $961.72
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$861.54 / $961.72 / $2,896.59
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,229.98 / $2,242.25 / $2,802.81
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,232.00 / $1,625.31 / $2,747.45
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,236.11 / $2,060.19 / $7,540.80
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,608.89 / $2,503.27 / $3,150.39
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,742.00 / $2,229.98 / $2,737.06
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,258.06 / $1,719.13 / $1,982.10
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,000.00 / $2,000.00 / $2,000.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,358.20 / $2,039.20 / $2,832.59
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,966.30 / $2,313.30 / $2,405.90