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Wisconsin rates for HCPCS L1845

Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$509.14 / $509.14 / $509.14
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$509.14 / $553.04 / $701.27
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,009.29 / $1,110.22 / $1,836.91
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$938.64 / $938.64 / $1,241.42
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$726.08 / $2,159.88 / $2,159.88
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$632.51 / $2,086.28 / $4,212.68
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$461.73 / $1,462.50 / $1,910.15
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$296.57 / $763.71 / $1,160.68
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$577.88 / $920.83 / $1,211.15
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$509.14 / $1,009.29 / $4,802.66
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$424.74 / $537.34 / $1,098.98
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $65.00 / $621.27
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$296.57 / $763.71 / $1,160.68
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$577.88 / $920.83 / $1,211.15
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,009.29 / $1,553.24 / $2,756.16
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$632.51 / $1,971.26 / $4,802.66
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$461.73 / $632.51 / $5,555.28
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,009.29 / $1,009.29 / $1,009.29
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$805.88 / $1,009.29 / $1,009.29
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$359.70 / $503.52 / $965.08