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South Dakota rates for HCPCS L6628

Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$575.54 / $575.54 / $575.54
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$551.02 / $575.54 / $748.67
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$444.49 / $444.49 / $776.59
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$796.50 / $796.50 / $995.63
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$482.45 / $778.60 / $2,994.68
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.42 / $454.94 / $807.04
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$645.72 / $776.59 / $1,103.40
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$653.49 / $787.51 / $1,484.04
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$639.47 / $748.67 / $889.90
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$224.60 / $432.19 / $682.41
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$691.87 / $691.87 / $691.87