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South Dakota rates for HCPCS L5857

Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$7,585.78 / $8,709.64 / $8,709.64
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,570.88 / $7,585.78 / $9,120.11
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6,606.93 / $6,606.93 / $11,481.54
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12,022.64 / $12,022.64 / $14,791.08
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$8,317.64 / $10,471.29 / $27,542.29
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,168.69 / $6,918.31 / $51,286.14
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$9,332.54 / $11,220.18 / $11,220.18
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11,481.54 / $11,481.54 / $11,481.54
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$9,332.54 / $9,332.54 / $18,620.87
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$8,709.64 / $10,471.29 / $13,803.84
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,073.80 / $6,918.31 / $10,964.78
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10,000.00 / $10,000.00 / $10,000.00