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Pennsylvania 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
$873.72 / $873.72 / $3,381.30
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$830.81 / $966.66 / $1,174.29
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,000.00 / $8,639.91 / $79,506.39
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,616.56 / $2,123.00 / $2,123.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,540.39 / $1,540.39 / $2,123.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,124.48 / $1,124.48 / $1,858.97
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,953.16 / $2,123.00 / $4,033.70
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$873.72 / $873.72 / $3,381.30
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$830.81 / $1,003.84 / $1,380.31
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,632.30 / $3,027.10 / $4,182.70
Priority Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,540.39 / $1,540.39 / $2,123.00
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,124.48 / $1,124.48 / $2,521.50
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,517.85 / $2,020.70 / $2,020.70
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,517.85 / $2,020.70 / $2,070.32
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$812.50 / $1,059.14 / $1,854.90