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South Dakota rates for HCPCS L4130

Replace pretibial shell

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$401.26 / $401.26 / $401.26
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$387.08 / $401.26 / $439.11
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$373.57 / $373.57 / $677.80
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$669.38 / $676.07 / $836.72
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$439.11 / $719.26 / $2,938.67
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$253.19 / $409.46 / $675.81
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$563.59 / $677.80 / $1,072.63
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$555.13 / $687.34 / $1,295.28
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$535.82 / $627.29 / $745.65
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$218.34 / $320.47 / $534.11
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$585.37 / $585.37 / $585.37