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South Dakota rates for HCPCS L5655

Addition to lower extremity, socket insert, below knee (BK) (Kemblo, Pelite, Aliplast, Plastazote or equal)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$229.09 / $288.40 / $288.40
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$162.18 / $229.09 / $346.74
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$218.78 / $218.78 / $354.81
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$398.11 / $398.11 / $489.78
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$275.42 / $338.84 / $851.14
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $213.80 / $2,041.74
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$288.40 / $346.74 / $346.74
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$354.81 / $354.81 / $354.81
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$288.40 / $288.40 / $575.44
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$263.03 / $316.23 / $416.87
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $213.80 / $363.08
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$309.03 / $309.03 / $309.03