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South Dakota rates for HCPCS L0112

Cranial Cervical Orthosis Congenital Torticollis Type With Or Without Soft Interface Material Adjustable Range Of Motion Joint Custom Fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,171.71 / $1,171.71 / $1,171.71
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,054.15 / $1,165.41 / $1,171.71
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$941.33 / $941.33 / $1,845.86
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,954.88 / $1,954.88 / $2,443.59
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,165.41 / $1,969.54 / $7,852.81
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$679.18 / $1,086.69 / $1,840.45
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,534.80 / $1,845.86 / $2,890.94
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,511.76 / $1,871.83 / $3,527.38
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,422.06 / $1,664.87 / $1,978.97
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$588.46 / $1,086.69 / $1,417.53
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,644.49 / $1,644.49 / $1,644.49