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South Dakota rates for HCPCS L1845

Knee orthosis (KO), double 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
$701.27 / $701.27 / $701.27
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.45 / $608.35 / $701.27
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$632.51 / $632.51 / $1,012.91
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,170.00 / $1,170.00 / $1,462.50
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$650.13 / $1,073.30 / $4,802.66
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$378.88 / $606.21 / $1,092.89
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$842.22 / $1,012.91 / $1,767.09
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$829.57 / $1,027.17 / $1,935.65
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$793.29 / $928.75 / $1,103.97
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$359.70 / $510.01 / $790.77
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$902.41 / $902.41 / $902.41