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New Hampshire 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
Facility
Modifier
Low / Median / High Price
$1,012.47 / $1,012.47 / $1,214.96
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$740.02 / $785.65 / $1,012.47
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,798.13 / $1,798.13 / $2,131.50
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,002.36 / $1,002.36 / $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 / $4,493.54
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$598.04 / $897.07 / $1,065.16
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,346.75 / $1,481.43 / $1,885.45