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Wisconsin rates for HCPCS L5858

Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11,220.18 / $11,220.18 / $11,220.18
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$9,772.37 / $11,220.18 / $19,054.61
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$22,908.68 / $22,908.68 / $38,018.94
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$19,498.45 / $21,379.62 / $25,703.96
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14,454.40 / $52,480.75 / $112,201.85
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10,715.19 / $32,359.37 / $43,651.58
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11,220.18 / $18,620.87 / $28,183.83
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$20,417.38 / $27,542.29 / $33,884.42
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11,220.18 / $22,387.21 / $104,712.85
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10,000.00 / $13,803.84 / $25,118.86
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$54.95 / $64.57 / $85.11
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$22,908.68 / $34,673.69 / $63,095.73
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14,454.40 / $45,708.82 / $104,712.85
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10,715.19 / $24,547.09 / $112,201.85
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12,022.64 / $15,135.61 / $32,359.37
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$8,317.64 / $11,220.18 / $19,054.61