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South Dakota rates for HCPCS L5701

Replacement, socket, above knee (AK)/knee disarticulation, including attachment plate, molded to patient model

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,847.77 / $3,847.77 / $3,847.77
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,714.37 / $3,847.77 / $4,439.27
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,550.04 / $2,550.04 / $5,234.93
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,325.75 / $5,325.75 / $6,657.19
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,252.23 / $5,253.33 / $21,140.73
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,811.00 / $3,067.56 / $5,219.62
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,352.77 / $5,234.93 / $7,831.52
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,287.43 / $5,308.63 / $10,003.87
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,791.81 / $4,439.27 / $5,276.78
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,594.13 / $2,714.61 / $3,779.76
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,663.85 / $4,663.85 / $4,663.85