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Wisconsin rates for HCPCS E2612

General use wheelchair back cushion, width 22 in or greater, any height, including any type mounting hardware

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$266.62 / $266.62 / $266.62
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$170.97 / $198.06 / $320.88
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$367.50 / $668.85 / $668.85
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$341.78 / $367.50 / $496.13
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$36.61 / $259.10 / $816.62
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$243.78 / $243.78 / $993.03
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$243.78 / $430.88 / $538.59
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$232.00 / $407.07 / $585.16
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$338.03 / $338.03 / $610.61
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$266.62 / $587.66 / $1,749.66
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$198.22 / $274.50 / $491.55
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $65.00 / $341.41
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$232.00 / $407.07 / $585.16
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$338.03 / $338.03 / $610.61
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$48.51 / $78.88 / $102.42
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$243.78 / $713.62 / $1,749.66
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$243.78 / $243.78 / $326.36
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$453.52 / $453.52 / $453.52
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$453.52 / $453.52 / $453.52
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$169.70 / $265.94 / $471.27