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South Dakota rates for HCPCS 72158

Mri Spinal Canal Lumbar W/O & W/Contr Matrl

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
26
Low / Median / High Price
$110.82 / $110.82 / $110.82
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$298.81 / $475.00 / $598.50
Aetna
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$101.85 / $168.21 / $523.20
Aetna
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$202.47 / $335.00 / $1,875.23
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$621.04 / $759.41 / $949.26
Cigna
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$201.73 / $246.67 / $308.33
Cigna
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$419.32 / $512.74 / $640.91
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$443.81 / $684.20 / $6,146.58
Medica
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$137.74 / $212.34 / $921.60
Medica
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$306.07 / $471.86 / $5,551.18
Midlands
Facility/Professional
Facility
Modifier
26
Low / Median / High Price
$372.18 / $372.18 / $372.18
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$691.70 / $830.63 / $1,459.73
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$454.09 / $597.39 / $751.06
Sanford Health Plan
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$140.62 / $184.41 / $210.24
Sanford Health Plan
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$308.41 / $397.65 / $518.88
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$393.46 / $684.20 / $858.60
United
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$126.38 / $206.60 / $247.53
United
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$264.83 / $459.11 / $579.52
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$723.60 / $851.30 / $851.30
Wellmark
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$241.90 / $284.60 / $284.60
Wellmark
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$481.60 / $566.60 / $566.60