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South Dakota rates for HCPCS L4631

Ankle-foot orthosis (AFO), walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,234.11 / $1,234.11 / $1,234.11
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$996.99 / $1,083.95 / $1,234.11
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,037.25 / $1,037.25 / $1,898.04
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,059.13 / $2,059.13 / $2,573.91
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,236.88 / $1,936.84 / $8,839.16
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$667.91 / $1,115.19 / $1,972.45
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,578.18 / $1,898.04 / $3,185.56
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,554.49 / $1,924.75 / $3,627.10
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,398.44 / $1,637.23 / $1,946.10
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$648.42 / $919.40 / $1,393.99
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,639.22 / $1,639.22 / $1,639.22