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South Dakota rates for HCPCS L4050

Replace Molded Calf Lacer, For Custom Fabricated Orthotic Only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$344.26 / $344.26 / $344.26
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$317.94 / $329.79 / $344.26
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$290.63 / $290.63 / $577.47
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$574.50 / $577.47 / $718.13
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$358.75 / $537.32 / $2,531.55
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$185.29 / $296.45 / $575.78
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$480.16 / $577.47 / $892.54
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$472.96 / $585.61 / $1,103.56
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$387.96 / $454.20 / $539.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$181.68 / $261.91 / $386.73
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$498.72 / $498.72 / $498.72