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South Dakota rates for HCPCS L2005

Knee Ankle Foot Orthosis Any Material Single Or Double Upright Stance Control Automatic Lock Andswing Phase Release Any Type Activation Includesankle Joint Any Type Custom Fabricated (Revised 010112)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,430.48 / $3,430.48 / $3,430.48
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,086.29 / $3,418.88 / $3,430.48
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,756.64 / $2,756.64 / $5,404.22
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,723.63 / $5,780.86 / $7,154.53
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,418.88 / $5,777.91 / $22,996.26
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,992.47 / $3,187.95 / $5,388.40
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,493.51 / $5,404.22 / $8,466.04
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,426.08 / $5,480.29 / $10,327.35
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,171.79 / $4,884.12 / $5,805.56
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,723.29 / $2,567.73 / $5,235.96
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,814.67 / $4,814.67 / $4,814.67