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South Dakota rates for HCPCS L5976

All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$594.23 / $594.23 / $594.23
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$590.92 / $594.23 / $708.73
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$420.01 / $420.01 / $832.85
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$822.38 / $830.60 / $1,027.97
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$539.08 / $864.93 / $3,565.60
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$289.12 / $482.74 / $865.50
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$692.49 / $832.85 / $1,289.90
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$682.09 / $844.55 / $1,591.53
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$605.36 / $708.73 / $842.44
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$262.57 / $447.11 / $603.42
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$742.00 / $742.00 / $742.00