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South Dakota rates for HCPCS A4617

Mouthpiece

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.76 / $2.76 / $2.76
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.27 / $1.39 / $3.63
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4.76 / $4.76 / $4.76
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4.88 / $4.88 / $6.09
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3.43 / $5.00 / $90.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.73 / $2.33 / $4.95
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4.00 / $4.76 / $5.71
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3.73 / $4.83 / $7.25
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3.61 / $4.30 / $5.44
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.44 / $2.16 / $4.33
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4.11 / $4.11 / $4.11