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Washington 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
$1,213.47 / $2,754.58 / $2,875.92
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,043.01 / $1,213.47 / $2,875.92
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,574.51 / $3,739.91 / $8,579.00
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,280.49 / $1,564.37 / $9,275.29
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 / $1,166.18
Kaiser Permanente
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,092.48 / $1,865.63 / $4,927.35
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,154.44 / $1,896.26 / $3,492.87
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,240.61 / $1,378.46 / $1,516.30
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,427.33 / $1,755.99 / $1,862.51
Pacific Source
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,528.41 / $1,798.13 / $1,977.94
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,574.51 / $2,019.39 / $3,511.98
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,711.49 / $1,755.99 / $1,755.99
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,428.46 / $1,528.41 / $1,977.94
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$759.14 / $885.66 / $1,566.48
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,002.36 / $1,528.41 / $1,528.41