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South Dakota rates for HCPCS L5703

Ankle, Symes, molded to patient model, socket without solid ankle cushion heel (SACH) foot, replacement only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,551.00 / $2,551.00 / $2,551.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,970.76 / $2,551.00 / $2,651.96
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,119.51 / $2,119.51 / $2,777.53
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,461.61 / $3,530.63 / $4,413.28
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,294.69 / $4,311.18 / $13,256.99
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,081.85 / $1,806.38 / $2,979.89
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,309.46 / $2,777.53 / $4,818.18
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,314.83 / $2,816.62 / $5,307.79
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,265.17 / $2,651.96 / $3,152.28
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,043.82 / $1,806.38 / $3,197.89
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,474.53 / $2,474.53 / $2,474.53