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Wisconsin rates for HCPCS V2104

Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$39.81 / $39.81 / $39.81
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$19.95 / $37.15 / $44.67
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$45.71 / $45.71 / $54.95
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$128.82 / $151.36 / $208.93
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21.88 / $70.79 / $93.33
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$35.48 / $40.74 / $48.98
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$43.65 / $81.28 / $107.15
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$38.02 / $45.71 / $100.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17.78 / $22.91 / $44.67
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.36 / $50.12 / $70.79
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$48.98 / $74.13 / $134.90
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$97.72 / $97.72 / $239.88
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21.88 / $74.13 / $288.40
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17.78 / $22.39 / $36.31