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South Dakota rates for HCPCS L5694

Addition to lower extremity, above knee (AK), pelvic control belt, padded and lined

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$182.38 / $182.38 / $182.38
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$169.95 / $182.38 / $237.05
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$140.85 / $140.85 / $239.51
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$252.38 / $254.90 / $315.47
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$182.13 / $280.64 / $1,167.33
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$96.71 / $161.47 / $258.42
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$199.16 / $239.51 / $417.86
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$206.92 / $242.89 / $457.70
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$202.48 / $237.05 / $281.77
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.06 / $144.84 / $201.84
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$213.39 / $213.39 / $213.39