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Wisconsin rates for HCPCS L4130

Replace Pretibial Shell

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$291.33 / $291.33 / $291.33
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$291.33 / $312.26 / $593.03
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$577.50 / $635.25 / $1,051.05
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$537.08 / $537.08 / $710.32
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$415.45 / $1,235.84 / $1,235.84
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$373.57 / $1,194.17 / $2,410.05
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$272.70 / $836.72 / $1,092.95
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$180.02 / $437.00 / $664.13
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$330.66 / $577.50 / $745.25
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$291.33 / $606.38 / $2,938.67
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$260.14 / $325.33 / $651.97
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $70.00 / $337.42
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$180.02 / $437.00 / $664.13
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$330.66 / $577.50 / $745.25
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$577.50 / $888.76 / $1,673.17
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$373.57 / $1,127.92 / $2,938.67
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$272.70 / $373.57 / $3,688.99
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$577.50 / $577.50 / $577.50
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$577.50 / $577.50 / $577.50
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.45 / $276.36 / $364.85
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$230.07 / $307.41 / $552.21