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Utah 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
$530.05 / $530.05 / $530.05
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$530.05 / $614.05 / $5,188.07
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 / $1,191.78 / $1,227.53
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$843.00 / $1,359.68 / $1,767.58
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,630.88 / $1,818.86 / $1,818.86
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,035.72 / $1,303.76 / $1,955.64
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$630.82 / $813.74 / $987.47