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South Dakota rates for HCPCS L5649

Addition to lower extremity, ischial containment/narrow M-L socket

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,478.41 / $2,478.41 / $2,478.41
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,783.56 / $2,478.41 / $2,484.86
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,800.00 / $1,800.00 / $2,513.71
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,243.49 / $3,430.50 / $4,288.13
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,083.94 / $2,941.48 / $11,959.60
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,013.70 / $1,717.71 / $2,889.61
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,090.10 / $2,513.71 / $4,385.35
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,168.98 / $2,549.08 / $4,803.62
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,122.46 / $2,484.86 / $2,953.66
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$892.65 / $1,520.07 / $2,115.69
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,239.48 / $2,239.48 / $2,239.48