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New Hampshire 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
$575.44 / $575.44 / $691.83
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$416.87 / $489.78 / $776.25
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,047.13 / $1,096.48 / $1,258.93
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$501.19 / $501.19 / $501.19
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$575.44 / $575.44 / $575.44
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$426.58 / $426.58 / $575.44
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$891.25 / $891.25 / $1,548.82
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$251.19 / $398.11 / $537.03
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$338.84 / $512.86 / $891.25
Well Sense
Facility/Professional
Facility
Modifier
Low / Median / High Price
$912.01 / $912.01 / $1,445.44