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SEWHFO, Shoulder Cap, without Joints, Custom Fabricated

South Dakota 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 $1,698 · 10th–90th $1,259$2,5700%10%10th90th$1,698Professionalmedian $1,585 · 10th–90th $1,148$2,6920%20%10th90th$1,585$1.0K$2.0K$5.0K$10.0K

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

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$1,348.96
Median
$1,348.96
Typical High
$1,348.96
Aetna
Setting
Professional
Modifier
Global
Typical Low
$1,148.15
Median
$1,258.93
Typical High
$1,584.89
Cigna
Setting
Facility
Modifier
Global
Typical Low
$1,202.26
Median
$1,202.26
Typical High
$2,041.74
Cigna
Setting
Professional
Modifier
Global
Typical Low
$2,137.96
Median
$2,137.96
Typical High
$2,691.53
Medica
Setting
Facility
Modifier
Global
Typical Low
$1,412.54
Median
$1,819.70
Typical High
$3,467.37
Medica
Setting
Professional
Modifier
Global
Typical Low
$741.31
Median
$1,230.27
Typical High
$9,332.54
Midlands
Setting
Professional
Modifier
Global
Typical Low
$1,659.59
Median
$1,995.26
Typical High
$1,995.26
Midlands
Setting
Facility
Modifier
Global
Typical Low
$2,041.74
Median
$2,041.74
Typical High
$2,041.74
Midlands
Setting
Professional
Modifier
Global
Typical Low
$1,659.59
Median
$1,659.59
Typical High
$3,311.31
Sanford Health Plan
Setting
Professional
Modifier
Global
Typical Low
$1,548.82
Median
$1,862.09
Typical High
$2,454.71
United
Setting
Facility
Modifier
Global
Typical Low
$912.01
Median
$954.99
Typical High
$1,380.38
United
Setting
Professional
Modifier
Global
Typical Low
$645.65
Median
$1,258.93
Typical High
$2,137.96
Wellmark
Setting
Professional
Modifier
Global
Typical Low
$1,778.28
Median
$1,778.28
Typical High
$1,778.28