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South Dakota rates for HCPCS L5858

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$18,792.59 / $18,792.59 / $18,792.59
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17,425.27 / $18,792.59 / $22,150.67
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14,513.81 / $14,513.81 / $24,558.72
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26,010.38 / $26,010.38 / $32,512.97
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$16,689.29 / $31,759.49 / $104,478.94
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$9,036.32 / $15,087.93 / $25,521.46
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$20,420.13 / $24,558.72 / $38,463.03
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$20,113.72 / $24,904.39 / $46,931.22
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$18,920.04 / $22,150.67 / $26,329.60
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$7,829.28 / $15,087.93 / $18,859.91
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21,879.59 / $21,879.59 / $21,879.59