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South Dakota rates for HCPCS L1851

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, off-the-shelf

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$530.75 / $530.75 / $530.75
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$438.73 / $615.59 / $677.14
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$636.97 / $712.60 / $984.92
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$748.13 / $755.61 / $935.16
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$616.52 / $1,041.92 / $3,153.85
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$435.42 / $727.02 / $1,154.24
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$983.95 / $989.89 / $1,344.67
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$984.92 / $1,064.46 / $2,075.52
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$626.41 / $725.91 / $853.99
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$227.18 / $562.11 / $908.77
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$877.47 / $877.47 / $877.47