go back

South Dakota rates for HCPCS L1904

Ankle orthosis (AO), ankle gauntlet or similar, with or without joints, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$377.87 / $377.87 / $377.87
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$334.56 / $349.99 / $377.87
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.03 / $331.03 / $585.83
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$630.38 / $630.38 / $787.97
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$363.93 / $612.03 / $2,763.54
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$211.05 / $337.68 / $628.76
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$487.10 / $585.83 / $1,016.64
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$479.77 / $594.05 / $1,119.49
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$441.90 / $517.35 / $614.95
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$211.05 / $352.39 / $628.76
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$521.91 / $521.91 / $521.91