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Wisconsin rates for HCPCS L4055

Replace Non-Molded Calf Lacer For Custom Fabricated Orthosis Only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$151.93 / $151.93 / $151.93
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$143.02 / $151.93 / $271.63
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$301.17 / $331.29 / $548.13
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$271.05 / $280.08 / $370.43
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$216.66 / $644.50 / $644.50
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.19 / $622.88 / $1,256.81
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.38 / $436.41 / $569.99
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$97.00 / $227.90 / $346.35
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$172.44 / $301.17 / $401.56
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$151.93 / $301.17 / $1,580.76
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$136.43 / $175.29 / $340.02
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $70.00 / $201.71
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$97.00 / $227.90 / $346.35
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$172.44 / $301.17 / $401.56
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$301.17 / $463.47 / $901.32
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.19 / $588.22 / $1,580.76
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.38 / $188.19 / $2,765.07
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$301.17 / $301.17 / $301.17
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$301.17 / $301.17 / $301.17
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$119.99 / $160.34 / $287.98