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Wisconsin rates for HCPCS 64495

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.83 / $186.21 / $3,467.37
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$48.98 / $89.13 / $263.03
Aetna
Facility/Professional
Professional
Modifier
50
Low / Median / High Price
$128.82 / $295.12 / $489.78
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,202.26 / $1,584.89 / $6,165.95
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.79 / $109.65 / $251.19
Anthem BCBS
Facility/Professional
Professional
Modifier
50
Low / Median / High Price
$112.20 / $169.82 / $380.19
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$57.54 / $57.54 / $57.54
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$112.20 / $112.20 / $112.20
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$245.47 / $281.84 / $457.09
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$87.10 / $204.17 / $416.87
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$53.70 / $107.15 / $3,162.28
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$93.33 / $162.18 / $251.19
DeanCare
Facility/Professional
Professional
Modifier
50
Low / Median / High Price
$141.25 / $239.88 / $371.54
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$56.23 / $117.49 / $1,659.59
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$95.50 / $173.78 / $2,511.89
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.36 / $33.11 / $85.11
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$87.10 / $158.49 / $323.59
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$131.83 / $131.83 / $2,630.27
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$97.72 / $346.74 / $2,511.89
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$158.49 / $309.03 / $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
$57.54 / $114.82 / $316.23