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Wisconsin rates for HCPCS L1902

Ankle Orthosis Ankle Gauntlet Or Similiar With Or Without Joints Prefabricated Off-The-Shelf (Revised 01/01/2016)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$45.37 / $45.37 / $62.98
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$42.00 / $56.20 / $131.75
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$89.93 / $98.92 / $163.66
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$77.77 / $83.63 / $110.61
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.70 / $107.92 / $192.45
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$89.93 / $94.43 / $129.56
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$58.00 / $185.74 / $375.08
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$42.34 / $130.31 / $170.21
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$28.97 / $67.59 / $103.42
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.50 / $89.93 / $107.92
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$45.37 / $89.93 / $472.21
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.74 / $53.37 / $97.93
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$41.82 / $55.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$28.97 / $68.06 / $103.42
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.50 / $89.93 / $107.92
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$89.93 / $138.41 / $268.99
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$58.00 / $175.66 / $472.21
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$42.34 / $58.00 / $593.54
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$89.93 / $89.93 / $89.93
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$71.81 / $89.93 / $89.93
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$35.13 / $44.94 / $84.05