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Wisconsin rates for HCPCS L5830

Addition Endoskeletal Knee-Shin System Single Axis Pneumatic/ Swing Phase Control

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,210.00 / $1,210.00 / $1,210.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$948.75 / $1,210.00 / $2,009.06
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,398.60 / $2,638.46 / $4,365.45
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,074.55 / $2,230.69 / $2,950.27
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,725.54 / $5,133.00 / $5,133.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,654.54 / $4,958.71 / $10,012.48
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,207.81 / $3,475.78 / $4,539.54
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$733.52 / $1,815.00 / $2,758.39
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,373.37 / $2,398.60 / $3,036.67
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,210.00 / $2,398.60 / $12,123.54
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,115.23 / $1,602.67 / $2,707.96
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $70.00 / $1,172.96
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$733.52 / $1,851.30 / $2,758.39
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,373.37 / $2,398.60 / $3,036.67
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,398.60 / $3,691.33 / $6,817.13
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,654.54 / $4,684.76 / $12,123.54
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,207.81 / $1,654.54 / $16,944.43
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,398.60 / $2,398.60 / $2,398.60
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,398.60 / $2,398.60 / $2,398.60
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$955.57 / $1,595.50 / $2,398.60