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Wisconsin rates for HCPCS L0455

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, off-the-shelf

Facilitymedian $229 · 10th–90th $224–$4170%20%40%10th90th$229Professionalmedian $209 · 10th–90th $135–$3470%20%10th90th$209$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
$138.04 / $138.04 / $138.04
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$117.49 / $141.25 / $245.47
Anthem BCBS
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$229.09 / $229.09 / $380.19
Anthem BCBS
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$213.80 / $229.09 / $257.04
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$275.42 / $933.25 / $1,288.25
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$204.17 / $380.19 / $426.58
DeanCare
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$138.04 / $223.87 / $346.74
DeanCare
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$223.87 / $338.84 / $380.19
Medica
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$138.04 / $251.19 / $1,148.15
Medica
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$186.21 / $218.78 / $478.63
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$54.95 / $70.79 / $199.53
Network Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$213.80 / $354.81 / $562.34
Quartz
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$186.21 / $269.15 / $524.81
Quartz
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$275.42 / $457.09 / $1,148.15
Quartz
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$204.17 / $371.54 / $1,737.80
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$131.83 / $208.93 / $346.74
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$138.04 / $208.93 / $323.59