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Wisconsin rates for HCPCS L0454

Thoracic-lumbar-sacral orthosis (TLSO), flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Facilitymedian $427 · 10th–90th $398–$7760%50%10th90th$427Professionalmedian $275 · 10th–90th $186–$6460%20%10th90th$275$0.5$2.0$10.0$50.0$200.0$1.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$208.93 / $208.93 / $208.93
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$177.83 / $208.93 / $309.03
Anthem BCBS
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$426.58 / $426.58 / $707.95
Anthem BCBS
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$316.23 / $398.11 / $467.74
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$234.42 / $977.24 / $2,089.30
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$169.82 / $602.56 / $812.83
DeanCare
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$208.93 / $346.74 / $524.81
DeanCare
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$380.19 / $549.54 / $691.83
Medica
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$208.93 / $416.87 / $1,949.84
Medica
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$186.21 / $218.78 / $467.74
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$54.95 / $70.79 / $346.74
Network Health
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$676.08 / $676.08 / $676.08
Network Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$302.00 / $478.63 / $831.76
Quartz
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$426.58 / $645.65 / $1,174.90
Quartz
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$234.42 / $851.14 / $1,949.84
Quartz
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$169.82 / $338.84 / $2,089.30
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$125.89 / $218.78 / $426.58
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$144.54 / $208.93 / $354.81