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South Dakota rates for HCPCS L1200

Thoracic-lumbar-sacral orthosis (TLSO), inclusive of furnishing initial orthosis only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,498.13 / $1,498.13 / $1,498.13
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,284.29 / $1,447.02 / $1,498.13
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,184.20 / $1,184.20 / $2,248.84
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,499.75 / $2,499.75 / $3,124.69
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,447.02 / $2,272.63 / $9,758.87
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$843.30 / $1,347.59 / $2,242.26
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,869.87 / $2,248.84 / $3,387.40
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,841.82 / $2,280.48 / $4,297.49
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,765.69 / $2,067.17 / $2,457.16
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$689.52 / $1,056.04 / $1,760.07
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,003.51 / $2,003.51 / $2,003.51