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Wisconsin rates for HCPCS L0622

Sacroiliac orthosis (SO), flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$162.46 / $162.46 / $162.46
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$139.10 / $162.46 / $264.17
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$322.04 / $354.24 / $586.11
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$278.52 / $299.50 / $396.10
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$231.68 / $689.17 / $689.17
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$181.86 / $711.30 / $1,343.58
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$132.76 / $474.35 / $609.49
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$93.74 / $243.69 / $370.35
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$184.39 / $322.04 / $388.06
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$162.26 / $322.04 / $1,549.83
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$134.25 / $172.71 / $363.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $70.00 / $173.99
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$93.74 / $243.69 / $370.35
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$184.39 / $322.04 / $388.06
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$322.04 / $495.61 / $871.21
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$181.86 / $628.98 / $1,549.83
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$132.76 / $181.86 / $1,979.55
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$322.04 / $322.04 / $322.04
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$322.04 / $322.04 / $322.04
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.23 / $143.90 / $189.98
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$121.00 / $169.40 / $350.66