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Wisconsin rates for HCPCS L5673

Addition To Lower Extremity Below Knee/Above Kneecustom Fabricated From Existing Mold Or Prefabricated Socket Insert Silicone Gel Elastomeric Or Equal For Use With Locking Mechanism

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$478.65 / $478.65 / $478.65
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$355.52 / $478.65 / $794.75
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$948.84 / $1,043.72 / $1,726.89
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$820.65 / $882.42 / $1,167.07
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$682.59 / $2,030.52 / $2,030.52
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$501.15 / $2,094.83 / $3,960.77
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$365.84 / $1,374.84 / $1,795.75
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$258.31 / $717.98 / $1,091.17
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$543.26 / $940.48 / $1,138.60
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$447.14 / $948.84 / $4,189.30
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$427.39 / $602.72 / $1,033.17
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $70.00 / $640.30
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$258.31 / $717.98 / $1,091.17
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$543.26 / $940.48 / $1,138.60
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$948.84 / $1,460.22 / $2,400.85
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$501.15 / $1,853.20 / $4,189.30
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$365.84 / $501.15 / $4,528.81
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$948.84 / $948.84 / $948.84
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$948.84 / $948.84 / $948.84
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$315.58 / $533.50 / $841.26