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Wisconsin rates for HCPCS L4205

Repair Of Orthotic Device Labor Component Per 15 Minutes (Special Coverage Instructions Apply. See Mcm: 2100.4)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$13.82 / $13.82 / $13.82
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.00 / $13.82 / $20.42
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$62.63 / $75.73 / $80.11
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21.25 / $25.00 / $27.00
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$20.54 / $62.34 / $62.34
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$22.22 / $94.62 / $146.94
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$16.22 / $23.02 / $44.06
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.00 / $23.30 / $33.50
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.13 / $34.96 / $47.87
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$13.82 / $29.13 / $159.28
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.55 / $16.60 / $32.83
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $65.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.00 / $23.30 / $33.50
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.13 / $34.96 / $47.87
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.13 / $55.06 / $90.33
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$22.22 / $54.80 / $159.28
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$16.22 / $22.22 / $158.43
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.13 / $29.13 / $29.13
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21.42 / $29.13 / $29.13
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.31 / $14.24 / $27.30