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South Dakota rates for HCPCS L3764

Elbow-wrist-hand orthosis (EWHO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$596.69 / $596.69 / $596.69
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$511.65 / $581.89 / $596.69
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$579.51 / $579.51 / $895.92
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$995.63 / $995.63 / $1,244.53
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$581.89 / $983.39 / $4,272.47
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$339.11 / $566.21 / $966.66
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$744.94 / $895.92 / $1,563.00
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$733.76 / $908.53 / $1,712.08
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$710.02 / $831.27 / $988.10
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$318.14 / $474.05 / $721.77
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$773.75 / $773.75 / $773.75