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Wisconsin rates for HCPCS L0626

Lumbar Orthosis Sagittal Control With Rigid Posterior Panel(S) Posterior Extends From L-1 To L-5 Vertebra Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs Includes Straps Closures May Include Padding Stays Shoulder Straps Pendulous Abdomen Design Pre- Fabricated Item That Has Been Trimmed Bent Molded Assembled Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise(Revised 01/01/14)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$47.38 / $47.38 / $47.38
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$44.85 / $49.16 / $65.25
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$93.91 / $103.30 / $170.92
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$84.51 / $87.34 / $115.50
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$67.56 / $200.97 / $200.97
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$58.60 / $207.37 / $391.88
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$42.78 / $138.11 / $177.74
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$27.03 / $71.06 / $108.00
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.78 / $91.65 / $112.69
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$46.78 / $93.91 / $437.39
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$41.02 / $49.20 / $102.26
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $63.38 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$27.03 / $71.06 / $108.00
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.78 / $91.65 / $112.69
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$93.91 / $144.53 / $250.93
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$58.60 / $183.42 / $437.39
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$42.78 / $58.60 / $473.70
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$93.91 / $93.91 / $93.91
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.00 / $93.91 / $93.91
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.78 / $46.85 / $93.91