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New Hampshire rates for HCPCS L3977

Shoulder-elbow-wrist-hand-finger orthosis (SEWHO), shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,122.02 / $1,122.02 / $1,348.96
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$831.76 / $1,071.52 / $1,778.28
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,041.74 / $2,187.76 / $2,511.89
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,122.02 / $1,122.02 / $1,122.02
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,348.96 / $1,348.96 / $1,348.96
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$977.24 / $977.24 / $1,348.96
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,778.28 / $1,778.28 / $3,090.30
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$562.34 / $912.01 / $1,202.26
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$691.83 / $1,000.00 / $1,778.28
Well Sense
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,819.70 / $1,819.70 / $2,884.03