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Montana rates for HCPCS L3764

Elbow-wrist-hand orthosis (EWHO), 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
Professional
Modifier
Low / Median / High Price
$408.98 / $2,994.64 / $2,994.64
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$579.51 / $893.78 / $893.78
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$579.51 / $893.78 / $893.78
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$579.51 / $851.22 / $893.78
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$579.51 / $670.82 / $894.42
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$367.25 / $406.33 / $621.79