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South Dakota rates for HCPCS L4000

Replace girdle for spinal orthosis (cervical-thoracic-lumbar-sacral orthosis (CTLSO) or spinal orthosis SO)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,106.25 / $1,106.25 / $1,106.25
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,003.72 / $1,106.25 / $1,113.64
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$897.58 / $897.58 / $1,757.56
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,845.75 / $1,864.21 / $2,307.19
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,113.64 / $1,752.41 / $7,517.91
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$649.01 / $1,038.42 / $1,752.41
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,461.37 / $1,757.56 / $2,756.58
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,439.45 / $1,782.30 / $3,358.64
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,358.89 / $1,590.91 / $1,891.05
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$561.11 / $836.07 / $1,354.56
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,517.89 / $1,517.89 / $1,517.89