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South Dakota rates for HCPCS L1755

Legg Perthes Orthotic, (Patten Bottom Type), Custom Fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,498.95 / $1,498.95 / $1,498.95
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,146.55 / $1,219.31 / $1,498.95
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,395.53 / $1,395.53 / $2,007.65
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,500.88 / $2,500.88 / $3,126.09
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,247.25 / $2,060.63 / $9,370.62
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$710.59 / $1,136.94 / $2,116.94
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,669.32 / $2,007.65 / $3,422.92
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,644.26 / $2,035.89 / $3,836.55
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,487.82 / $1,741.87 / $2,070.48
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$696.75 / $987.91 / $1,483.09
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,788.64 / $1,788.64 / $1,788.64