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SEWHFO, Shoulder Cap, without Joints, Custom Fabricated

Pennsylvania 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

Rates data updated July 2026.

Facilitymedian $2,239 · 10th–90th $741$8,7100%20%10th90th$2,239Professionalmedian $871 · 10th–90th $741$1,7780%20%40%10th90th$871$2.0$10.0$50.0$200.0$1.0K$5.0K$20.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$741.31
Median
$741.31
Typical High
$2,884.03
Aetna
Setting
Professional
Modifier
Global
Typical Low
$707.95
Median
$870.96
Typical High
$1,288.25
Capital Blue Cross
Setting
Facility
Modifier
Global
Typical Low
$5,011.87
Median
$8,511.38
Typical High
$77,624.71
Capital Blue Cross
Setting
Professional
Modifier
Global
Typical Low
$1,778.28
Median
$1,778.28
Typical High
$1,778.28
Cigna
Setting
Facility
Modifier
Global
Typical Low
$1,202.26
Median
$1,202.26
Typical High
$2,570.40
Cigna
Setting
Professional
Modifier
Global
Typical Low
$870.96
Median
$870.96
Typical High
$1,202.26
Emblem Health
Setting
Professional
Modifier
Global
Typical Low
$1,698.24
Median
$2,398.83
Typical High
$3,467.37
Geisinger
Setting
Facility
Modifier
Global
Typical Low
$1,819.70
Median
$1,819.70
Typical High
$1,819.70
Geisinger
Setting
Professional
Modifier
Global
Typical Low
$1,096.48
Median
$1,288.25
Typical High
$1,819.70
Martin's Point
Setting
Facility
Modifier
Global
Typical Low
$741.31
Median
$741.31
Typical High
$2,884.03
Martin's Point
Setting
Professional
Modifier
Global
Typical Low
$741.31
Median
$870.96
Typical High
$1,513.56
UPMC Health Plan
Setting
Facility
Modifier
Global
Typical Low
$1,698.24
Median
$6,456.54
Typical High
$10,471.29
UPMC Health Plan
Setting
Professional
Modifier
Global
Typical Low
$1,288.25
Median
$1,698.24
Typical High
$1,737.80
United
Setting
Facility
Modifier
Global
Typical Low
$758.58
Median
$2,238.72
Typical High
$2,238.72
United
Setting
Professional
Modifier
Global
Typical Low
$691.83
Median
$891.25
Typical High
$1,862.09