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Wisconsin rates for HCPCS L5681

Addition To Lower Extremity Below Knee/Above Knee Custom Fabricated Socketinsert For Congenital Or Atypical Traumatic Amputee Silicone Gel Elastomericor Equal For Use With Or Without Locking Mechanism Initial Only (For Other Than Initial Use Code L5673 Or L5679)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$801.07 / $801.07 / $801.07
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$665.09 / $801.07 / $1,342.10
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,587.98 / $1,746.78 / $2,890.12
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,476.82 / $1,476.82 / $1,953.21
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,142.39 / $3,398.28 / $3,398.28
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$886.63 / $3,506.43 / $6,628.34
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$647.24 / $2,301.09 / $3,005.38
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$457.00 / $1,201.60 / $1,826.18
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$909.23 / $1,549.90 / $1,905.58
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$791.08 / $1,587.98 / $7,396.37
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$725.28 / $1,061.04 / $1,729.11
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $70.00 / $957.56
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$457.00 / $1,201.60 / $1,826.18
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$909.23 / $1,549.90 / $1,905.58
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,587.98 / $2,443.85 / $4,247.66
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$886.63 / $3,101.52 / $7,396.37
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$647.24 / $886.63 / $8,010.83
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,587.98 / $1,587.98 / $1,587.98
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,587.98 / $1,587.98 / $1,587.98
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$589.91 / $952.79 / $1,587.98