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Wisconsin rates for HCPCS L4030

Replace quadrilateral socket brim, custom fitted

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$372.66 / $372.66 / $372.66
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$270.12 / $372.66 / $513.29
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$738.73 / $812.60 / $1,344.49
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$664.85 / $687.02 / $908.63
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$531.44 / $1,580.88 / $1,580.88
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$477.88 / $1,527.20 / $3,083.24
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$348.85 / $1,230.33 / $1,398.11
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$183.20 / $558.99 / $849.54
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$422.99 / $738.73 / $886.48
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$317.12 / $738.73 / $3,084.21
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$281.23 / $368.54 / $804.39
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $70.00 / $395.42
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$183.20 / $558.99 / $849.54
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$422.99 / $738.73 / $886.48
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$738.73 / $1,108.09 / $1,702.28
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$477.88 / $1,442.84 / $3,084.21
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$348.85 / $477.88 / $3,708.18
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$738.73 / $738.73 / $738.73
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$738.73 / $738.73 / $738.73
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$245.70 / $368.54 / $706.38