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South Dakota rates for HCPCS L6694

Addition To Upper Extremity Prosthesis Below Elbow/Above Elbow Custom

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$794.75 / $794.75 / $794.75
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$701.74 / $794.75 / $888.09
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$528.74 / $528.74 / $989.01
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,099.88 / $1,099.88 / $1,374.84
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$650.62 / $1,343.13 / $4,189.10
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$362.30 / $604.91 / $1,027.79
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$822.35 / $989.01 / $1,539.11
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$810.00 / $1,002.93 / $1,889.98
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$758.56 / $888.09 / $1,055.63
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$313.29 / $533.50 / $756.15
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$881.12 / $881.12 / $881.12