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Wisconsin rates for HCPCS L1902

Ankle orthosis (AO), ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$44.67 / $44.67 / $69.18
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$44.67 / $64.57 / $158.49
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$91.20 / $91.20 / $151.36
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$77.62 / $85.11 / $102.33
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$81.28 / $112.20 / $190.55
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$128.82 / $128.82 / $128.82
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$57.54 / $208.93 / $446.68
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$42.66 / $128.82 / $173.78
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$38.02 / $69.18 / $107.15
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$81.28 / $134.90 / $169.82
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$45.71 / $89.13 / $467.74
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.74 / $53.70 / $102.33
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$41.69 / $58.88 / $85.11
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$91.20 / $138.04 / $281.84
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$57.54 / $181.97 / $489.78
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$42.66 / $85.11 / $588.84
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$41.69 / $47.86 / $147.91
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$35.48 / $44.67 / $77.62