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South Dakota rates for HCPCS L5697

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.86 / $93.33 / $93.33
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$41.69 / $75.86 / $107.15
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$60.26 / $60.26 / $107.15
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$128.82 / $128.82 / $162.18
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$77.62 / $104.71 / $281.84
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$41.69 / $69.18 / $645.65
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$89.13 / $104.71 / $107.15
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$107.15 / $107.15 / $107.15
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$89.13 / $89.13 / $186.21
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$87.10 / $104.71 / $138.04
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$41.69 / $69.18 / $114.82
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$95.50 / $95.50 / $95.50