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South Dakota rates for HCPCS L1843

Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$751.17 / $751.17 / $751.17
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$320.37 / $580.03 / $751.17
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$702.03 / $702.03 / $1,183.35
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,253.25 / $1,253.25 / $1,566.56
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$747.14 / $1,262.67 / $5,034.28
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$435.42 / $696.66 / $1,179.91
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$983.95 / $1,183.35 / $1,853.33
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$969.18 / $1,200.02 / $2,261.39
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$911.66 / $1,067.33 / $1,268.71
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$377.25 / $545.26 / $908.77
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,054.26 / $1,054.26 / $1,054.26