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South Dakota rates for HCPCS L7403

Addition To Upper Extremity Prosthesis Below Elbow/Wrist Disarticulation Acrylic Material

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$372.39 / $372.39 / $372.39
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$345.28 / $372.39 / $438.91
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$286.80 / $286.80 / $486.63
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$515.25 / $520.40 / $644.05
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$330.70 / $629.34 / $2,070.19
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$179.05 / $298.95 / $505.70
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$404.61 / $486.63 / $762.15
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$398.54 / $493.46 / $929.92
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$374.89 / $438.91 / $521.71
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$165.11 / $298.95 / $471.36
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$433.54 / $433.54 / $433.54