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Wisconsin rates for HCPCS L5683

Addition To Lower Extremity Below Knee/Above Knee Custom Fabricated Socket Insert For Other Than Congenital Or Atypical Traumatic Amputee Siliconegel Elastomeric Or Equal For Use With Or Without Locking Mechanism Initial Only(For Other Than I Nitial 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
$950.52 / $3,506.43 / $6,628.34
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$693.88 / $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
$950.52 / $3,101.52 / $7,396.37
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$693.88 / $950.52 / $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 / $1,407.92