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South Dakota rates for HCPCS L5698

Addition to lower extremity, above knee (AK) or knee disarticulation, Silesian bandage

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$120.65 / $120.65 / $120.65
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$108.63 / $120.65 / $122.26
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$99.25 / $99.25 / $153.10
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$166.88 / $166.88 / $208.59
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$105.79 / $161.90 / $682.16
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.88 / $83.28 / $159.10
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$127.31 / $153.10 / $240.26
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.40 / $155.27 / $292.62
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$104.43 / $122.26 / $145.33
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$48.90 / $69.44 / $104.10
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$136.40 / $136.40 / $136.40