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Wisconsin rates for HCPCS L4631

Ankle Foot Orthosis Walking Boot Type Varus/ Valgus Correction Rocker Bottom Anterior Tibial Shell Soft Interface Custom Arch Support Plastic Or Other Material Includes Straps And Closures Custom Fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$896.00 / $896.00 / $896.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$858.50 / $912.91 / $1,234.11
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,776.15 / $1,953.77 / $3,232.59
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,598.53 / $1,651.82 / $2,184.66
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,277.77 / $3,800.96 / $3,800.96
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,037.25 / $3,921.18 / $7,413.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$757.19 / $2,573.91 / $3,361.50
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$896.00 / $1,420.92 / $2,042.57
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,776.15 / $2,131.38 / $2,213.30
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,083.95 / $1,776.15 / $8,839.16
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$800.08 / $985.07 / $2,017.70
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $65.00 / $926.80
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$896.00 / $1,420.92 / $2,042.57
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,776.15 / $2,131.38 / $2,213.30
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,776.15 / $2,733.47 / $4,969.32
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,037.25 / $3,469.04 / $8,839.16
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$757.19 / $1,037.25 / $10,623.84
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,776.15 / $1,776.15 / $1,776.15
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,776.15 / $1,776.15 / $1,776.15
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$690.12 / $957.11 / $1,776.15