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South Dakota rates for HCPCS L5200

Above knee (AK), molded socket, single axis constant friction knee, shin, SACH foot

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,675.58 / $3,675.58 / $3,675.58
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,304.15 / $3,675.58 / $3,872.04
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,728.17 / $2,728.17 / $4,656.78
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,087.25 / $5,087.25 / $6,359.06
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,350.41 / $5,104.88 / $20,802.65
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,579.59 / $2,637.44 / $4,839.34
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,872.03 / $4,656.78 / $7,608.90
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,813.92 / $4,722.34 / $8,899.02
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,307.31 / $3,872.04 / $4,602.54
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,548.82 / $2,637.44 / $3,296.80
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,148.77 / $4,148.77 / $4,148.77