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South Dakota rates for HCPCS 77301

Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
26
Low / Median / High Price
$430.71 / $430.71 / $430.71
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,664.03 / $2,114.63 / $3,320.59
Aetna
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$368.80 / $416.68 / $1,206.83
Aetna
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,292.05 / $1,745.82 / $2,807.44
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,568.99 / $4,364.09 / $5,455.11
Cigna
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$798.04 / $975.83 / $1,219.79
Cigna
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$2,770.95 / $3,388.26 / $4,235.32
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,783.83 / $3,485.57 / $4,334.38
Medica
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$496.31 / $788.71 / $1,161.70
Medica
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,719.84 / $2,718.18 / $4,446.34
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,660.00 / $4,169.06 / $5,050.79
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,089.15 / $3,149.91 / $3,595.47
Sanford Health Plan
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$491.29 / $682.51 / $822.21
Sanford Health Plan
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,647.14 / $2,443.58 / $2,773.26
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,174.79 / $2,372.50 / $3,954.16
United
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$454.95 / $511.60 / $918.70
United
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,712.45 / $2,718.18 / $3,283.33
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,425.10 / $4,029.50 / $4,029.50
Wellmark
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$783.30 / $921.50 / $921.50
Wellmark
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$2,641.90 / $3,108.10 / $3,108.10