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South Dakota rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$209.26 / $209.26 / $209.26
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$202.29 / $205.88 / $209.26
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.19 / $188.19 / $354.22
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$349.13 / $352.62 / $436.41
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$220.05 / $347.94 / $1,580.76
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$119.99 / $191.98 / $357.45
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$294.52 / $354.22 / $577.95
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$290.10 / $359.20 / $676.90
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$251.21 / $294.11 / $349.60
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$117.64 / $191.98 / $397.54
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.92 / $305.92 / $305.92