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South Dakota rates for HCPCS L5679

Addition to lower extremity, below knee (BK)/above knee (AK), custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric, or equal, with or without perforations, with or without breathable material, 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