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South Dakota rates for HCPCS L5626

Addition to lower extremity, test socket, hip disarticulation

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$639.09 / $639.09 / $639.09
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$456.74 / $558.84 / $639.09
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$493.58 / $493.58 / $643.72
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$729.46 / $884.63 / $1,105.78
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$472.74 / $736.63 / $3,080.66
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$227.98 / $380.66 / $679.19
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$535.24 / $643.72 / $1,098.18
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$527.22 / $652.78 / $1,230.13
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$477.34 / $558.84 / $664.28
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$223.54 / $380.66 / $679.19
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$573.50 / $573.50 / $573.50