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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
$426.58 / $426.58 / $426.58
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,905.46 / $2,137.96 / $4,466.84
Aetna
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$398.11 / $436.52 / $1,202.26
Aetna
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,513.56 / $1,778.28 / $4,677.35
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,073.80 / $4,466.84 / $5,623.41
Cigna
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$912.01 / $1,000.00 / $1,258.93
Cigna
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$3,162.28 / $3,467.37 / $4,365.16
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,778.28 / $2,570.40 / $4,365.16
Medica
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$398.11 / $660.69 / $2,187.76
Medica
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,288.25 / $2,041.74 / $3,311.31
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,365.16 / $4,365.16 / $4,365.16
Midlands
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$977.24 / $977.24 / $977.24
Midlands
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$3,388.44 / $3,388.44 / $3,388.44
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,398.83 / $3,162.28 / $3,630.78
Sanford Health Plan
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$501.19 / $691.83 / $812.83
Sanford Health Plan
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,862.09 / $2,511.89 / $2,754.23
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,187.76 / $2,884.03 / $4,265.80
United
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$457.09 / $660.69 / $933.25
United
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,698.24 / $2,187.76 / $3,388.44
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,388.44 / $4,073.80 / $4,073.80
Wellmark
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$776.25 / $912.01 / $912.01
Wellmark
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$2,630.27 / $3,090.30 / $3,090.30