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South Dakota rates for HCPCS 77300

Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
26
Low / Median / High Price
$33.47 / $33.47 / $33.47
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$59.23 / $68.76 / $111.47
Aetna
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$28.73 / $62.58 / $460.80
Aetna
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$30.41 / $40.02 / $63.06
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$128.13 / $156.69 / $195.86
Cigna
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$62.17 / $76.02 / $95.02
Cigna
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$65.98 / $80.67 / $100.84
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$64.54 / $120.89 / $150.46
Medica
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$38.84 / $61.26 / $90.89
Medica
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$40.86 / $61.29 / $98.36
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$126.00 / $150.00 / $176.55
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.95 / $108.53 / $130.66
Sanford Health Plan
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$38.61 / $53.09 / $64.04
Sanford Health Plan
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$37.33 / $56.64 / $66.63
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.09 / $80.59 / $133.91
United
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$38.75 / $59.60 / $72.80
United
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$40.34 / $48.93 / $76.56
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$124.50 / $146.40 / $146.40
Wellmark
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$61.00 / $71.80 / $71.80
Wellmark
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$63.50 / $74.70 / $74.70