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New Mexico 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
$1,072.29 / $1,072.29 / $1,072.29
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,072.29 / $1,646.74 / $6,125.35
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,540.39 / $1,540.39 / $1,540.39
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,124.48 / $1,540.39 / $1,540.39
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,749.41 / $2,186.77 / $3,280.15
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$625.83 / $625.83 / $1,643.36
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,124.48 / $1,540.39 / $2,487.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$880.20 / $969.40 / $1,460.26