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South Dakota rates for HCPCS L3730

Elbow orthosis (EO), double upright with forearm/arm cuffs, extension/ flexion assist, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$690.50 / $690.50 / $690.50
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$679.34 / $690.50 / $743.41
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$620.97 / $620.97 / $1,301.75
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,152.00 / $1,163.52 / $1,440.00
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$808.71 / $1,148.08 / $5,297.15
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$395.91 / $633.45 / $1,297.94
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,082.38 / $1,301.75 / $1,907.09
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,066.14 / $1,320.06 / $2,487.61
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$828.94 / $970.49 / $1,153.58
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$388.20 / $578.41 / $826.31
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,124.24 / $1,124.24 / $1,124.24