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South Dakota rates for HCPCS L5679

Addition To Lower Extremity Below Knee/Above Kneecustom Fabricated Fromexisting Mold Or Prefabric Ated Socket Insert Silicone Gel Elastomeric Or Equal Not For Use With Locking Mechanism

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$662.27 / $662.27 / $662.27
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$584.79 / $662.27 / $740.03
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$440.05 / $440.05 / $824.19
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$916.50 / $916.50 / $1,145.63
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$542.15 / $1,119.24 / $3,490.95
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$301.89 / $504.07 / $821.78
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$685.29 / $824.19 / $1,282.56
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$674.99 / $835.77 / $1,574.97
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$632.10 / $740.03 / $879.64
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$261.07 / $502.37 / $790.68
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$734.27 / $734.27 / $734.27