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South Dakota rates for HCPCS L3967

Shoulder-elbow-wrist-hand orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,511.33 / $1,511.33 / $1,511.33
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,359.71 / $1,503.22 / $1,511.33
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,540.39 / $1,540.39 / $2,380.90
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,521.50 / $2,521.50 / $3,151.88
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,503.22 / $2,540.44 / $10,128.96
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$876.05 / $1,401.68 / $2,373.94
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,979.67 / $2,380.90 / $3,728.90
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,949.98 / $2,414.41 / $4,549.85
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,834.26 / $2,147.46 / $2,552.60
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$759.03 / $1,130.96 / $2,306.17
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,056.23 / $2,056.23 / $2,056.23