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Utah 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
$262.32 / $262.32 / $262.32
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$262.32 / $354.45 / $2,994.64
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$579.51 / $579.51 / $579.51
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$423.04 / $579.51 / $810.24
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$385.27 / $621.41 / $807.83
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$745.35 / $831.27 / $831.27
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$473.35 / $595.85 / $893.78
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$366.88 / $406.33 / $582.94