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Wisconsin rates for HCPCS L5704

Custom Shaped Protective Cover Below Knee

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$380.87 / $380.87 / $380.87
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$268.00 / $380.87 / $632.39
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$755.01 / $830.51 / $1,374.12
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$679.50 / $702.16 / $928.66
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$543.15 / $1,615.72 / $1,615.72
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$394.91 / $1,560.94 / $3,151.82
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$288.27 / $1,094.06 / $1,428.91
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$203.55 / $571.30 / $868.26
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$432.30 / $731.90 / $906.01
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$352.34 / $755.01 / $3,305.62
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$340.10 / $474.94 / $822.11
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $70.00 / $440.46
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$203.55 / $571.30 / $868.26
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$432.30 / $731.90 / $906.01
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$755.01 / $1,161.92 / $1,891.97
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$394.91 / $1,474.62 / $3,305.62
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$288.27 / $394.91 / $3,622.91
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$755.01 / $755.01 / $755.01
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$602.86 / $755.01 / $755.01
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$262.75 / $453.01 / $647.53