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South Dakota rates for HCPCS L1620

Hip Orthosis Abduction Control Of Hip Joints Flexible (Pavlik Harness) Prefabricated Item That Has Been Trimmed Bent Molded Assembled Orotherwise Customized To Fit A Specific Patient By An Individual With Expertise (Revised 01/01/14)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$131.54 / $131.54 / $131.54
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.06 / $97.87 / $131.54
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$117.36 / $117.36 / $171.38
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$192.41 / $219.38 / $274.22
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$106.45 / $174.37 / $791.34
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.13 / $100.41 / $179.15
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$142.49 / $171.38 / $289.68
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$140.33 / $173.77 / $327.47
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.91 / $147.40 / $175.21
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.13 / $87.86 / $179.15
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$152.68 / $152.68 / $152.68