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South Dakota rates for HCPCS L5628

Addition To Lower Extremity Test Socket Hemipelvectomy

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$647.16 / $647.16 / $647.16
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$474.06 / $565.91 / $647.16
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$499.82 / $499.82 / $668.13
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$738.68 / $895.88 / $1,119.83
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$489.68 / $746.15 / $3,076.44
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$230.87 / $385.47 / $694.32
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$555.53 / $668.13 / $1,112.06
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$547.21 / $677.54 / $1,276.78
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$483.38 / $565.91 / $672.67
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$226.36 / $385.47 / $513.54
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$595.24 / $595.24 / $595.24