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Utah 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
$530.05 / $530.05 / $530.05
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$530.05 / $614.05 / $5,188.07
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,028.38 / $1,028.38 / $1,028.38
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$750.72 / $750.72 / $2,135.63
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$843.00 / $1,359.68 / $1,767.58
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,630.88 / $1,818.86 / $1,818.86
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,035.72 / $1,303.76 / $1,955.64
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$642.88 / $821.06 / $964.33