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Wisconsin rates for HCPCS L5500

Initial, below knee (BK) PTB type socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, direct formed

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$898.06 / $898.06 / $898.06
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$642.15 / $898.06 / $1,491.12
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,780.23 / $1,958.25 / $3,240.02
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,655.61 / $1,655.61 / $2,189.67
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,280.69 / $3,809.69 / $3,809.69
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$963.22 / $3,680.08 / $7,430.29
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$703.15 / $2,580.00 / $3,369.24
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$496.48 / $1,347.09 / $2,047.26
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,019.32 / $1,780.23 / $2,136.28
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$859.42 / $1,780.23 / $8,261.60
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$801.91 / $1,158.45 / $1,938.45
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $70.00 / $1,040.29
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$496.48 / $1,347.09 / $2,047.26
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,019.32 / $1,780.23 / $2,136.28
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,780.23 / $2,739.73 / $4,614.01
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$963.22 / $3,477.02 / $8,261.60
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$703.15 / $963.23 / $10,112.74
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,780.23 / $1,780.23 / $1,780.23
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,780.23 / $1,780.23 / $1,780.23
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$695.07 / $1,158.71 / $1,780.23