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Wisconsin rates for HCPCS L3675

Shoulder Orthosis Vest Type Abduction Restrainer Canvas Webbing Type Or Equal Prefabricated Off- The-Shelf (Revised 01/01/14)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$97.09 / $97.09 / $97.09
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$91.88 / $97.09 / $174.49
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$192.46 / $211.71 / $350.28
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$173.21 / $178.99 / $236.72
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$138.46 / $411.86 / $411.86
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$107.42 / $397.74 / $803.35
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$78.42 / $278.91 / $364.25
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$55.36 / $144.66 / $221.33
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$110.18 / $187.82 / $230.95
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$95.84 / $192.46 / $899.40
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$84.03 / $102.02 / $209.57
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $65.58 / $109.30
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$55.36 / $145.63 / $221.33
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$110.18 / $187.82 / $230.95
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$192.46 / $296.18 / $514.90
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$107.42 / $375.90 / $899.40
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$78.42 / $107.42 / $968.61
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$192.46 / $192.46 / $192.46
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$153.66 / $192.46 / $192.46
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.14 / $85.00 / $100.06
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$67.15 / $96.02 / $192.46