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SEWHFO, Shoulder Cap, without Joints, Custom Fabricated

Texas 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 $1,445 · 10th–90th $813$3,8020%10%20%10th90th$1,445Professionalmedian $871 · 10th–90th $776$1,3800%50%10th90th$871$2.0$10.0$50.0$200.0$1.0K$5.0K

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
$831.76
Median
$851.14
Typical High
$1,071.52
Aetna
Setting
Professional
Modifier
Global
Typical Low
$776.25
Median
$870.96
Typical High
$1,202.26
Christus
Setting
Facility
Modifier
Global
Typical Low
$79.43
Median
$1,905.46
Typical High
$1,905.46
Cigna
Setting
Facility
Modifier
Global
Typical Low
$1,202.26
Median
$1,202.26
Typical High
$1,202.26
Cigna
Setting
Professional
Modifier
Global
Typical Low
$870.96
Median
$870.96
Typical High
$1,202.26
Lucent Health
Setting
Facility
Modifier
Global
Typical Low
$8,709.64
Median
$8,709.64
Typical High
$8,709.64
Lucent Health
Setting
Professional
Modifier
Global
Typical Low
$9,549.93
Median
$13,489.63
Typical High
$13,489.63
Moda Health
Setting
Facility
Modifier
Global
Typical Low
$776.25
Median
$1,584.89
Typical High
$2,511.89
Moda Health
Setting
Professional
Modifier
Global
Typical Low
$1,122.02
Median
$1,737.80
Typical High
$1,905.46
Molina
Setting
Professional
Modifier
Global
Typical Low
$812.83
Median
$933.25
Typical High
$933.25
Providence
Setting
Facility
Modifier
Global
Typical Low
$776.25
Median
$1,445.44
Typical High
$2,511.89
Providence
Setting
Professional
Modifier
Global
Typical Low
$870.96
Median
$870.96
Typical High
$1,202.26
United
Setting
Facility
Modifier
Global
Typical Low
$676.08
Median
$1,513.56
Typical High
$1,905.46
United
Setting
Professional
Modifier
Global
Typical Low
$691.83
Median
$1,000.00
Typical High
$1,174.90
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$977.24
Median
$1,905.46
Typical High
$2,570.40