go back

South Dakota rates for HCPCS L3961

Shoulder-elbow-wrist-hand orthosis (SEWHO), shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,280.08 / $1,280.08 / $1,280.08
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,151.65 / $1,273.20 / $1,280.08
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,028.38 / $1,028.38 / $2,016.60
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,135.63 / $2,156.98 / $2,669.53
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,273.20 / $2,151.71 / $8,579.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$742.00 / $1,187.20 / $2,010.69
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,676.75 / $2,016.60 / $3,158.31
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,651.60 / $2,044.95 / $3,853.63
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,553.58 / $1,818.86 / $2,162.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$642.88 / $957.91 / $1,842.32
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,741.61 / $1,741.61 / $1,741.61