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Maine rates for HCPCS L3975

Shoulder-elbow-wrist-hand-finger orthosis (SEWHO), shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$859.54 / $1,091.44 / $1,091.44
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,599.26 / $2,071.98 / $3,840.81
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,002.36 / $1,050.24 / $1,050.24
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,191.78 / $1,191.78 / $1,191.78
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$870.00 / $870.00 / $1,191.78
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,455.87 / $1,455.87 / $1,455.87
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,012.47 / $1,091.44 / $1,091.44
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$632.62 / $897.07 / $2,062.98