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Wisconsin rates for HCPCS L5700

Replacement, socket, below knee (BK), molded to patient model

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,867.99 / $1,867.99 / $1,867.99
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,432.56 / $1,867.99 / $3,101.56
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,702.93 / $4,073.22 / $6,739.33
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,202.65 / $3,443.72 / $4,554.60
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,663.87 / $7,924.27 / $7,924.27
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,400.00 / $7,655.67 / $15,456.78
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,752.00 / $5,366.25 / $7,008.08
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,058.63 / $2,801.99 / $4,258.37
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,120.21 / $3,702.93 / $4,443.52
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,832.53 / $3,702.93 / $17,077.79
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,668.00 / $2,467.67 / $4,099.52
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $70.00 / $2,498.94
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,058.63 / $2,801.99 / $4,258.37
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,120.21 / $3,702.93 / $4,443.52
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,702.93 / $5,698.67 / $9,839.27
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,400.00 / $7,232.28 / $17,077.79
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,752.00 / $2,400.00 / $21,693.67
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,702.93 / $3,702.93 / $3,702.93
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,956.71 / $3,702.93 / $3,702.93
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,366.51 / $2,166.90 / $3,175.83