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South Dakota rates for HCPCS L4030

Replace quadrilateral socket brim, custom fitted

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$513.29 / $513.29 / $513.29
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$368.76 / $388.83 / $513.29
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$477.88 / $477.88 / $645.71
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$856.50 / $856.50 / $1,070.63
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$401.14 / $657.12 / $3,084.21
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$226.60 / $362.56 / $675.08
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$536.89 / $645.71 / $1,091.54
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$528.84 / $654.79 / $1,233.94
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$474.45 / $555.47 / $660.26
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$222.19 / $331.06 / $504.06
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$557.66 / $557.66 / $557.66