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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
$11,318.27 / $11,318.27 / $11,318.27
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$9,397.00 / $11,318.27 / $18,962.38
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$22,436.32 / $24,679.95 / $40,834.10
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$19,405.16 / $20,865.78 / $27,596.67
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$16,140.65 / $48,013.72 / $48,013.72
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14,513.81 / $49,537.69 / $93,650.43
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10,595.08 / $33,033.18 / $42,462.49
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6,455.32 / $16,977.41 / $25,801.77
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12,846.50 / $21,898.50 / $26,923.58
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11,174.41 / $22,436.32 / $104,478.94
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10,245.00 / $14,991.32 / $24,430.38
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $65.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6,455.32 / $16,977.41 / $25,801.77
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12,846.50 / $21,898.50 / $26,923.58
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$22,436.32 / $34,528.74 / $59,997.17
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14,513.81 / $43,820.94 / $104,478.94
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10,595.08 / $14,513.81 / $112,957.80
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$22,436.32 / $22,436.32 / $22,436.32
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$22,436.32 / $22,436.32 / $22,436.32
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$8,332.68 / $13,213.37 / $19,242.64