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South Dakota rates for HCPCS L2628

Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,311.47 / $1,311.47 / $1,311.47
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,185.71 / $1,311.47 / $1,720.36
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,179.41 / $1,179.41 / $2,076.23
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,188.13 / $2,188.13 / $2,735.16
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,452.42 / $2,555.94 / $10,013.70
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$855.00 / $1,440.97 / $2,516.63
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,726.34 / $2,076.23 / $3,622.14
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,879.86 / $2,145.21 / $4,511.68
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,099.21 / $2,457.65 / $2,921.30
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$737.30 / $1,133.99 / $2,092.54
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,849.73 / $1,849.73 / $1,849.73