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Wisconsin rates for HCPCS L4370

Pneumatic Full Leg Splint Prefabricated Off-The-Shelf (Revised 01/01/14)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$143.06 / $143.06 / $143.06
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$101.00 / $143.06 / $197.04
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$283.58 / $311.94 / $516.12
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$245.26 / $263.73 / $348.80
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$204.00 / $606.86 / $606.86
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$150.11 / $586.30 / $1,184.03
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$109.58 / $411.09 / $536.69
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$68.50 / $214.59 / $326.12
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$162.38 / $212.68 / $340.30
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$118.58 / $283.58 / $1,107.57
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$105.16 / $141.47 / $308.79
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $65.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$68.50 / $214.59 / $326.12
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$162.38 / $212.68 / $340.30
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$283.58 / $425.37 / $636.35
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$150.11 / $553.86 / $1,107.57
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$109.58 / $150.11 / $1,403.72
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$283.58 / $283.58 / $283.58
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$226.43 / $283.58 / $283.58
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$94.32 / $141.47 / $265.26