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Wisconsin rates for HCPCS L5679

Addition To Lower Extremity Below Knee/Above Kneecustom Fabricated Fromexisting Mold Or Prefabric Ated Socket Insert Silicone Gel Elastomeric Or Equal Not For Use With Locking Mechanism

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$398.87 / $398.87 / $398.87
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$296.25 / $398.87 / $662.27
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$790.68 / $869.75 / $1,439.04
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$672.07 / $735.33 / $972.53
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$568.82 / $1,692.06 / $1,692.06
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$440.05 / $1,746.21 / $3,300.17
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$321.24 / $1,145.63 / $1,496.43
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$215.25 / $598.30 / $909.28
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$452.72 / $783.72 / $948.82
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$372.61 / $790.68 / $3,490.95
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$356.17 / $502.25 / $860.95
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $70.00 / $533.58
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$215.25 / $598.30 / $909.28
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$452.72 / $783.72 / $948.82
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$790.68 / $1,216.83 / $2,000.37
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$440.05 / $1,544.30 / $3,490.95
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$321.24 / $440.05 / $3,773.79
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$790.68 / $790.68 / $790.68
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$790.68 / $790.68 / $790.68
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$315.00 / $474.41 / $790.68