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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
$735.01 / $735.01 / $735.01
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$681.54 / $735.01 / $866.36
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$624.54 / $624.54 / $960.55
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,017.38 / $1,017.38 / $1,271.72
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$652.78 / $1,242.17 / $4,086.48
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$353.43 / $590.12 / $998.20
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$798.69 / $960.55 / $1,504.40
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$786.70 / $974.08 / $1,835.59
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$740.00 / $866.36 / $1,029.80
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$306.22 / $521.46 / $737.65
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$855.77 / $855.77 / $855.77