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South Dakota rates for HCPCS L5685

Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$129.54 / $129.54 / $129.54
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$120.11 / $129.54 / $152.66
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.03 / $100.03 / $169.28
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$179.25 / $179.25 / $224.06
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$115.00 / $218.92 / $720.06
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.28 / $103.99 / $175.90
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$140.75 / $169.28 / $265.08
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.63 / $171.65 / $323.45
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$130.40 / $152.66 / $181.47
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.96 / $103.83 / $129.99
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$150.81 / $150.81 / $150.81