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Wisconsin rates for HCPCS L1850

Knee Orthosis Swedish Type Prefabricated Off- The- Shelf (Revised 01/01/14)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$129.87 / $129.87 / $129.87
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$129.87 / $140.13 / $256.79
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$224.35 / $246.79 / $408.32
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$208.65 / $208.65 / $275.95
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$246.93 / $480.11 / $480.11
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$214.95 / $709.18 / $916.71
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$156.91 / $325.27 / $422.11
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$104.44 / $194.81 / $269.22
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$196.54 / $200.37 / $269.22
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$129.87 / $258.00 / $1,096.95
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$149.58 / $188.74 / $303.05
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $70.00 / $218.82
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$104.44 / $215.30 / $269.22
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$196.54 / $200.37 / $269.22
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$224.35 / $441.11 / $596.20
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$214.95 / $435.62 / $1,096.95
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$156.91 / $214.95 / $1,674.36
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$294.07 / $294.07 / $294.07
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$274.08 / $294.07 / $322.45
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$136.75 / $176.44 / $294.39