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South Dakota rates for HCPCS L6697

Addition To Upper Extremity Prosthesis Below Elbow/Above Elbow Custom

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,330.08 / $1,330.08 / $1,330.08
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,233.29 / $1,330.08 / $1,570.90
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,111.22 / $1,111.22 / $1,738.15
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,840.88 / $1,859.28 / $2,301.09
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,181.21 / $2,247.84 / $7,396.37
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$640.85 / $1,070.02 / $1,806.30
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,445.25 / $1,738.15 / $2,722.96
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,423.56 / $1,762.61 / $3,321.58
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,341.78 / $1,570.90 / $1,867.26
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$554.27 / $943.85 / $1,337.52
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,548.54 / $1,548.54 / $1,548.54