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South Dakota rates for HCPCS L5696

Addition to lower extremity, above knee (AK) or knee disarticulation, pelvic joint

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$198.04 / $198.04 / $198.04
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$185.01 / $198.04 / $216.86
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$138.76 / $138.76 / $260.76
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$274.13 / $274.13 / $342.66
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$187.66 / $285.70 / $1,184.51
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$88.47 / $147.72 / $270.95
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$216.81 / $260.76 / $426.16
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$213.55 / $264.42 / $498.28
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$185.23 / $216.86 / $257.77
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$86.74 / $147.72 / $196.80
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$232.31 / $232.31 / $232.31