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South Dakota rates for HCPCS L6895

Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$675.28 / $675.28 / $675.28
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$599.13 / $668.94 / $675.28
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$418.79 / $418.79 / $844.40
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$873.17 / $934.50 / $1,168.13
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$524.59 / $863.23 / $3,451.92
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$272.89 / $455.65 / $877.50
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$702.10 / $844.40 / $1,286.14
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$691.57 / $856.28 / $1,613.63
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$571.39 / $668.94 / $795.14
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$261.80 / $455.65 / $806.21
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$752.29 / $752.29 / $752.29