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Wisconsin rates for HCPCS L5654

Addition To Lower Extremity Socket Insert Symes (Kemblo Pelite Aliplast Plastazote Or Equal)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$238.77 / $238.77 / $238.77
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$165.82 / $238.77 / $396.44
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$473.30 / $520.63 / $861.41
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$409.35 / $440.17 / $582.15
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$340.49 / $1,012.86 / $1,012.86
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$306.16 / $978.41 / $1,976.18
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$223.50 / $685.78 / $895.76
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$128.19 / $358.16 / $544.29
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$270.99 / $473.30 / $567.96
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$221.92 / $473.30 / $2,089.06
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$212.27 / $299.14 / $515.37
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $70.00 / $268.62
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$128.19 / $358.16 / $544.29
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$270.99 / $473.30 / $567.96
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$473.30 / $728.41 / $1,191.39
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$306.16 / $924.42 / $2,089.06
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$223.50 / $306.16 / $2,347.44
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$473.30 / $473.30 / $473.30
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$473.30 / $473.30 / $473.30
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$157.41 / $264.77 / $458.20