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Utah 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
$594.04 / $594.04 / $594.04
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$594.04 / $688.20 / $5,814.44
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,335.63 / $1,335.63 / $1,335.63
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$975.01 / $1,335.63 / $1,375.70
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$944.75 / $1,523.80 / $1,980.94
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,827.73 / $2,038.40 / $2,038.40
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,160.74 / $1,461.12 / $2,191.69
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$706.97 / $911.97 / $1,080.74