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Montana 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
Professional
Modifier
Low / Median / High Price
$836.54 / $6,125.35 / $6,125.35
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,540.39 / $2,308.94 / $2,308.94
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,540.39 / $2,308.94 / $2,308.94
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,083.33 / $2,199.00 / $2,308.94
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,540.39 / $1,732.97 / $2,310.62
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$876.16 / $969.40 / $1,109.69