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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
$286.23 / $286.23 / $286.23
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$248.47 / $286.23 / $310.89
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$221.07 / $221.07 / $350.19
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$396.00 / $396.00 / $495.00
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$269.01 / $422.38 / $1,741.43
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$126.83 / $211.77 / $377.84
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$291.18 / $350.19 / $610.91
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$286.81 / $355.12 / $669.21
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$265.55 / $310.89 / $369.54
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$124.36 / $158.83 / $264.70
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$311.98 / $311.98 / $311.98