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West Virginia 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
$928.96 / $928.96 / $928.96
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$865.98 / $889.07 / $928.96
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,203.98 / $2,427.48 / $3,146.73
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,168.78 / $1,296.59 / $2,222.73
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,191.78 / $1,191.78 / $2,170.64
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$870.00 / $1,191.78 / $8,835.64
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$688.17 / $897.07 / $1,407.35