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South Dakota rates for HCPCS L5781

Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,548.13 / $4,073.80 / $4,073.80
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,137.96 / $3,548.13 / $4,265.80
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,884.03 / $2,884.03 / $5,370.32
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,623.41 / $5,623.41 / $7,079.46
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,890.45 / $5,011.87 / $13,182.57
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,949.84 / $3,235.94 / $24,547.09
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,365.16 / $5,248.07 / $5,248.07
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,370.32 / $5,370.32 / $5,370.32
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,365.16 / $4,365.16 / $8,709.64
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,073.80 / $4,897.79 / $6,456.54
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,905.46 / $3,235.94 / $5,128.61
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,677.35 / $4,677.35 / $4,677.35