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South Dakota rates for HCPCS L3960

Shoulder-elbow-wrist-hand orthosis (SEWHO), abduction positioning, airplane design, prefabricated, includes fitting and adjustment

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$607.66 / $607.66 / $607.66
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$421.94 / $486.62 / $559.61
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$510.00 / $516.29 / $976.82
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,014.00 / $1,014.00 / $1,267.50
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$606.85 / $936.01 / $4,248.13
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$322.77 / $516.44 / $973.96
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$812.21 / $976.82 / $1,554.80
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$800.02 / $990.57 / $1,866.66
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$675.82 / $791.22 / $940.48
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$316.49 / $448.74 / $673.67
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$843.62 / $843.62 / $843.62