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Wisconsin rates for HCPCS L0628

Lumbar-Sacral Orthosis Flexible Provides Lumbo-Sacral Support Posterior Extends From Sacro- Coccygeal Juntion To T-9 Vertebra Produces Intra-Cavitary Pressure To Reduce Load On The Inter- Vertebral Discs Includes Straps Closures May Include Stays Shoulder Straps Pendulous Abdomen Design Prefabricated Off-The-Shelf (Revised 01/01/14)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$33.53 / $33.53 / $33.53
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$33.53 / $38.40 / $69.81
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$53.86 / $59.25 / $98.03
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.09 / $53.86 / $66.23
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$72.70 / $115.26 / $115.26
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$57.67 / $209.19 / $257.52
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$42.10 / $89.20 / $101.36
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$29.09 / $50.63 / $64.63
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$27.95 / $57.86 / $64.63
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$33.53 / $63.39 / $275.93
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$41.66 / $52.56 / $86.68
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $63.38 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$29.09 / $53.86 / $64.63
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$27.95 / $57.86 / $64.63
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.86 / $65.47 / $123.39
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$57.67 / $104.60 / $275.93
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$42.10 / $57.67 / $420.15
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$82.26 / $82.26 / $82.26
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$80.70 / $82.26 / $94.94
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$37.54 / $50.42 / $86.68