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South Dakota rates for HCPCS L1852

Knee Orthosis (Ko) Double Upright Thigh And Calfwith 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
$502.50 / $502.50 / $502.50
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$418.55 / $586.95 / $645.64
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$621.29 / $647.80 / $881.60
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$713.63 / $881.60 / $892.03
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$560.10 / $991.95 / $3,006.95
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$378.88 / $615.51 / $1,100.54
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$842.22 / $886.50 / $1,206.89
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$881.60 / $955.42 / $1,865.34
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$597.58 / $678.58 / $814.69
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$216.72 / $535.96 / $790.77
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$785.42 / $785.42 / $785.42