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South Dakota rates for HCPCS L6638

Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,528.64 / $2,528.64 / $2,528.64
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,344.69 / $2,528.64 / $2,980.50
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,952.91 / $1,952.91 / $3,304.54
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,499.88 / $3,499.88 / $4,374.84
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,245.62 / $4,273.39 / $14,058.21
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,215.89 / $2,030.17 / $3,434.09
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,747.66 / $3,304.54 / $5,175.39
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,706.42 / $3,351.04 / $6,314.89
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,545.80 / $2,980.50 / $3,542.80
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,053.47 / $1,793.93 / $3,200.81
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,944.05 / $2,944.05 / $2,944.05