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Wisconsin rates for HCPCS L0492

Thoracic-lumbar-sacral orthosis (TLSO), sagittal-coronal control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

Facilitymedian $617 · 10th–90th $575–$1,1220%20%40%10th90th$617Professionalmedian $398 · 10th–90th $269–$9120%20%10th90th$398$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
$302.00 / $302.00 / $302.00
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$257.04 / $302.00 / $426.58
Anthem BCBS
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$616.60 / $616.60 / $1,023.29
Anthem BCBS
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$575.44 / $575.44 / $691.83
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$380.19 / $1,412.54 / $3,019.95
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$275.42 / $870.96 / $1,174.90
DeanCare
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$302.00 / $501.19 / $758.58
DeanCare
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$346.74 / $602.56 / $724.44
Medica
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$302.00 / $602.56 / $2,818.38
Medica
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$263.03 / $316.23 / $676.08
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$54.95 / $70.79 / $467.74
Network Health
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$977.24 / $977.24 / $977.24
Network Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$436.52 / $691.83 / $1,202.26
Quartz
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$616.60 / $912.01 / $1,698.24
Quartz
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$380.19 / $1,230.27 / $2,951.21
Quartz
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$275.42 / $549.54 / $3,019.95
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$181.97 / $309.03 / $616.60
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$208.93 / $302.00 / $512.86