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Ankle Orthosis, Gauntlet, Off-the-Shelf

South Dakota rates for HCPCS L1902

Ankle orthosis (AO), ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf

Rates data updated July 2026.

Facilitymedian $89 · 10th–90th $62$1230%20%10th90th$89Professionalmedian $79 · 10th–90th $54$1290%10%10th90th$79$50.0$100.0$200.0$500.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Small sample; interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$66.07
Median
$66.07
Typical High
$66.07
Aetna
Setting
Professional
Modifier
Global
Typical Low
$53.70
Median
$63.10
Typical High
$95.50
Avera
Setting
Facility
Modifier
Global
Typical Low
$89.13
Median
$89.13
Typical High
$89.13
Avera
Setting
Professional
Modifier
Global
Typical Low
$81.28
Median
$95.50
Typical High
$100.00
Cigna
Setting
Facility
Modifier
Global
Typical Low
$57.54
Median
$57.54
Typical High
$107.15
Cigna
Setting
Professional
Modifier
Global
Typical Low
$104.71
Median
$104.71
Typical High
$128.82
Medica
Setting
Facility
Modifier
Global
Typical Low
$75.86
Median
$93.33
Typical High
$169.82
Medica
Setting
Professional
Modifier
Global
Typical Low
$35.48
Median
$69.18
Typical High
$588.84
Midlands
Setting
Professional
Modifier
Global
Typical Low
$87.10
Median
$104.71
Typical High
$104.71
Midlands
Setting
Facility
Modifier
Global
Typical Low
$107.15
Median
$107.15
Typical High
$107.15
Midlands
Setting
Professional
Modifier
Global
Typical Low
$87.10
Median
$87.10
Typical High
$162.18
Sanford Health Plan
Setting
Professional
Modifier
Global
Typical Low
$75.86
Median
$89.13
Typical High
$120.23
United
Setting
Facility
Modifier
Global
Typical Low
$50.12
Median
$52.48
Typical High
$74.13
United
Setting
Professional
Modifier
Global
Typical Low
$35.48
Median
$69.18
Typical High
$104.71
Wellmark
Setting
Professional
Modifier
Global
Typical Low
$95.50
Median
$95.50
Typical High
$95.50