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South Dakota rates for HCPCS L4040

Replace Molded Thigh Lacer, For Custom Fabricated Orthotic Only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$347.60 / $347.60 / $347.60
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$304.52 / $328.16 / $347.60
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$352.55 / $352.55 / $533.25
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$580.13 / $580.13 / $725.16
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.28 / $554.59 / $2,469.31
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$191.25 / $305.99 / $545.79
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$443.38 / $533.25 / $882.50
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$436.73 / $540.74 / $1,019.00
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$400.43 / $468.80 / $557.24
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$179.64 / $254.70 / $399.15
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$460.53 / $460.53 / $460.53