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South Dakota rates for HCPCS L3740

Elbow orthosis (EO), double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$818.65 / $818.65 / $818.65
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$786.32 / $805.42 / $818.65
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$736.22 / $736.22 / $1,376.89
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,365.75 / $1,376.89 / $1,707.19
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$855.39 / $1,361.16 / $6,310.18
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$469.38 / $751.01 / $1,398.36
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,144.84 / $1,376.89 / $2,261.02
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,127.68 / $1,396.26 / $2,631.19
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$982.78 / $1,150.59 / $1,367.67
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$460.24 / $685.76 / $1,178.21
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,189.13 / $1,189.13 / $1,189.13