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Wisconsin rates for HCPCS 0628T

Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; each additional level (List separately in addition to code for primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$44.67 / $44.67 / $17,782.79
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$45.71 / $72.44 / $85.11
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.86 / $141.25 / $371.54
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$102.33 / $102.33 / $323.59
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$52.48 / $144.54 / $3,801.89
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$63.10 / $147.91 / $1,778.28
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.11 / $138.04 / $549.54
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.12 / $64.57 / $70.79
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.00 / $177.83 / $251.19
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$190.55 / $190.55 / $478.63
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$302.00 / $537.03 / $537.03
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,023.29 / $1,584.89 / $1,949.84
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$81.28 / $117.49 / $323.59