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Wisconsin rates for HCPCS L7401

Addition To Upper Extremity Prosthesis Above Elbow Disarticulation Ultralight Material (Titanium Carbon Fiber Or Equal)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$208.93 / $208.93 / $208.93
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$173.49 / $208.93 / $350.09
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$414.17 / $455.59 / $753.79
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$380.92 / $385.18 / $509.42
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$297.95 / $886.32 / $886.32
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$267.94 / $914.65 / $1,728.46
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$195.60 / $609.60 / $783.84
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$119.17 / $313.39 / $476.30
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$237.15 / $404.30 / $497.00
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$206.30 / $414.17 / $1,928.91
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$189.13 / $276.75 / $450.98
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $65.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$119.17 / $313.39 / $476.30
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$237.15 / $404.30 / $497.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$414.17 / $637.38 / $1,108.08
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$267.94 / $808.92 / $1,928.91
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$195.60 / $267.94 / $2,085.52
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$414.17 / $414.17 / $414.17
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$414.17 / $414.17 / $414.17
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$153.84 / $248.50 / $414.17