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Wisconsin rates for HCPCS L0638

Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$801.65 / $801.65 / $801.65
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$758.74 / $801.65 / $1,440.99
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,589.13 / $1,748.04 / $2,892.22
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,374.43 / $1,477.89 / $1,954.62
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,143.22 / $3,400.74 / $3,400.74
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,115.23 / $3,508.42 / $6,632.53
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$814.12 / $2,339.82 / $3,007.54
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$457.21 / $1,202.48 / $1,827.50
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$909.90 / $1,551.00 / $1,906.96
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$791.46 / $1,589.13 / $7,399.97
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$693.91 / $832.44 / $1,730.36
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $70.00 / $1,072.43
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$457.21 / $1,202.48 / $1,827.50
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$909.90 / $1,551.00 / $1,906.96
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,589.13 / $2,445.61 / $4,249.67
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,115.23 / $3,103.76 / $7,399.97
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$814.12 / $1,115.23 / $8,000.67
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,589.13 / $1,589.13 / $1,589.13
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,268.88 / $1,589.13 / $1,589.13
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$554.53 / $792.80 / $1,519.53