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South Dakota rates for HCPCS L5622

Addition to lower extremity, test socket, knee disarticulation

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$403.85 / $403.85 / $403.85
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$341.64 / $403.85 / $424.92
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$274.54 / $274.54 / $481.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$559.13 / $559.13 / $698.91
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$367.68 / $560.17 / $2,359.33
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$173.35 / $289.43 / $516.41
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$400.35 / $481.49 / $835.02
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$394.33 / $488.25 / $920.10
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$362.94 / $424.92 / $505.09
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$169.97 / $289.43 / $385.59
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$428.97 / $428.97 / $428.97