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Wisconsin rates for HCPCS L5971

All lower extremity prostheses, solid ankle cushion heel (SACH) foot, replacement only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$132.28 / $132.28 / $132.28
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$101.55 / $132.28 / $219.64
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$262.23 / $288.45 / $477.26
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$226.79 / $243.87 / $322.54
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.64 / $561.16 / $561.16
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$159.21 / $579.04 / $1,094.46
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$116.22 / $386.24 / $496.29
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$78.51 / $198.42 / $301.56
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$150.15 / $262.23 / $314.68
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$132.28 / $262.23 / $1,295.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$121.61 / $175.23 / $296.07
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $70.00 / $204.02
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$78.51 / $198.42 / $301.56
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$150.15 / $262.23 / $314.68
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$262.23 / $403.55 / $729.69
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$159.21 / $512.16 / $1,295.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$116.22 / $159.21 / $1,472.02
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$262.23 / $262.23 / $262.23
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$262.23 / $262.23 / $262.23
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$104.47 / $174.42 / $224.90