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SEWHFO, Shoulder Cap, without Joints, Custom Fabricated

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

Rates data updated July 2026.

Facilitymedian $813 · 10th–90th $525$1,8620%20%40%10th90th$813Professionalmedian $1,047 · 10th–90th $525$7,7620%10%10th90th$1,047$50.0$100.0$200.0$500.0$1.0K$2.0K$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
$524.81
Median
$524.81
Typical High
$524.81
Aetna
Setting
Professional
Modifier
Global
Typical Low
$524.81
Median
$831.76
Typical High
$7,762.47
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
Molina
Setting
Professional
Modifier
Global
Typical Low
$60.26
Median
$1,348.96
Typical High
$1,737.80
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$1,778.28
Median
$1,862.09
Typical High
$1,862.09
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$1,047.13
Median
$1,318.26
Typical High
$1,995.26
Select Health
Setting
Facility
Modifier
Global
Typical Low
$1,905.46
Median
$1,905.46
Typical High
$1,905.46
Select Health
Setting
Professional
Modifier
Global
Typical Low
$954.99
Median
$1,819.70
Typical High
$1,905.46
U of Utah Health Plan
Setting
Professional
Modifier
Global
Typical Low
$1,318.26
Median
$1,905.46
Typical High
$2,187.76
United
Setting
Facility
Modifier
Global
Typical Low
$691.83
Median
$812.83
Typical High
$1,698.24
United
Setting
Professional
Modifier
Global
Typical Low
$645.65
Median
$812.83
Typical High
$1,258.93