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Nebraska 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
Facility
Modifier
Low / Median / High Price
$519.40 / $519.40 / $519.40
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$519.40 / $519.40 / $674.45
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$715.84 / $787.42 / $795.38
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$579.51 / $895.92 / $895.92
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$579.51 / $895.92 / $1,381.53
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$430.25 / $891.51 / $4,272.47
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$310.08 / $406.33 / $677.22
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$893.30 / $895.92 / $1,237.31
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$811.19 / $1,073.76 / $1,845.75
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$310.08 / $406.33 / $626.15