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South Dakota rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Facilitymedian $234 · 10th–90th $209–$3890%20%40%10th90th$234Professionalmedian $219 · 10th–90th $138–$4370%20%10th90th$219$100.0$200.0$500.0$1.0K$2.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Small sample — interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$208.93 / $208.93 / $208.93
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$138.04 / $204.17 / $269.15
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$186.21 / $186.21 / $363.08
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$346.74 / $346.74 / $436.52
Medica
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$229.09 / $309.03 / $562.34
Medica
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$120.23 / $213.80 / $2,754.23
Midlands
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$295.12 / $354.81 / $354.81
Midlands
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$363.08 / $363.08 / $363.08
Midlands
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$295.12 / $295.12 / $537.03
Sanford Health Plan
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$251.19 / $302.00 / $398.11
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$117.49 / $213.80 / $354.81
Wellmark
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$309.03 / $309.03 / $309.03