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Wisconsin rates for HCPCS 21085

Impression & Preparation Oral Surgical Splint

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$476.90 / $1,012.59 / $2,554.41
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$476.90 / $670.42 / $2,703.14
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,314.00 / $2,550.00 / $4,471.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$639.05 / $1,100.53 / $3,139.21
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$292.58 / $292.58 / $292.58
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,806.75 / $2,111.33 / $3,238.83
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$780.56 / $1,890.18 / $3,131.40
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$476.90 / $775.64 / $1,433.27
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$499.50 / $916.00 / $1,707.40
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$792.17 / $1,571.50 / $5,095.68
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.75 / $561.24 / $1,509.49
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$476.90 / $775.64 / $1,433.27
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,120.50 / $1,591.33 / $2,332.71
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$255.06 / $255.06 / $2,226.84
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,033.33 / $2,900.79 / $5,095.68
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,135.89 / $3,093.73 / $4,385.43
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,034.00 / $1,423.00 / $2,202.90
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$753.16 / $1,359.46 / $3,115.34