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South Dakota rates for HCPCS L7405

Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$645.65 / $741.31 / $741.31
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$389.05 / $645.65 / $776.25
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$630.96 / $630.96 / $977.24
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,023.29 / $1,023.29 / $1,258.93
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$707.95 / $891.25 / $2,398.83
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$354.81 / $588.84 / $4,466.84
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$794.33 / $954.99 / $954.99
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$977.24 / $977.24 / $977.24
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$794.33 / $794.33 / $1,584.89
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$741.31 / $891.25 / $1,174.90
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$346.74 / $588.84 / $933.25
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$851.14 / $851.14 / $851.14