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South Dakota rates for HCPCS L5624

Addition to lower extremity, test socket, above knee (AK)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$403.69 / $403.69 / $403.69
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$340.57 / $403.69 / $427.46
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$311.77 / $311.77 / $480.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$557.96 / $558.75 / $698.44
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$369.87 / $562.41 / $2,310.33
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$174.38 / $328.00 / $517.89
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$399.10 / $480.00 / $837.38
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$393.12 / $486.74 / $917.24
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$365.11 / $427.46 / $508.11
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$170.45 / $218.37 / $363.95
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$427.63 / $427.63 / $427.63