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Wisconsin rates for HCPCS L3762

Elbow Orthosis Rigid Without Joints Includes Soft Interface Material Prefabricated Off-The- Shelf (Revised 01/01/14)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$59.47 / $59.47 / $59.47
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$56.30 / $63.25 / $123.25
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$117.89 / $129.68 / $214.56
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$106.10 / $109.64 / $145.00
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$84.81 / $252.28 / $252.28
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$65.81 / $260.47 / $492.65
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$48.04 / $170.63 / $223.13
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$33.93 / $88.61 / $135.57
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$67.51 / $115.08 / $141.47
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$58.73 / $117.89 / $549.05
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.49 / $61.75 / $128.37
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$35.95 / $55.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$33.93 / $89.21 / $135.57
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$67.51 / $115.08 / $141.47
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$117.89 / $181.44 / $315.16
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$65.81 / $230.26 / $549.05
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$48.04 / $65.81 / $593.47
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$117.89 / $117.89 / $117.89
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$117.89 / $117.89 / $117.89
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$168.53 / $168.53 / $168.53
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$46.97 / $58.81 / $112.72