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Lumbar Derotation Pad for TLSO (Low Profile)

Wisconsin rates for HCPCS L1240

Addition to thoracic-lumbar-sacral orthosis (TLSO), (low profile), lumbar derotation pad

Rates data updated July 2026.

Facilitymedian $112 · 10th–90th $83$2240%50%10th90th$112Professionalmedian $105 · 10th–90th $54$1740%20%10th90th$105$0.1$0.5$2.0$10.0$50.0$200.0

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
Setting
Facility
Modifier
Global
Typical Low
$54.95
Median
$54.95
Typical High
$54.95
Aetna
Setting
Professional
Modifier
Global
Typical Low
$54.95
Median
$54.95
Typical High
$100.00
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$112.20
Median
$112.20
Typical High
$186.21
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$100.00
Median
$104.71
Typical High
$123.03
Cigna
Setting
Facility
Modifier
Global
Typical Low
$63.10
Median
$257.04
Typical High
$575.44
Cigna
Setting
Professional
Modifier
Global
Typical Low
$45.71
Median
$162.18
Typical High
$213.80
DeanCare
Setting
Facility
Modifier
Global
Typical Low
$54.95
Median
$91.20
Typical High
$138.04
DeanCare
Setting
Professional
Modifier
Global
Typical Low
$100.00
Median
$131.83
Typical High
$162.18
Medica
Setting
Facility
Modifier
Global
Typical Low
$54.95
Median
$109.65
Typical High
$467.74
Medica
Setting
Professional
Modifier
Global
Typical Low
$43.65
Median
$54.95
Typical High
$120.23
Molina
Setting
Professional
Modifier
Global
Typical Low
$50.12
Median
$70.79
Typical High
$85.11
Network Health
Setting
Facility
Modifier
Global
Typical Low
$177.83
Median
$177.83
Typical High
$177.83
Network Health
Setting
Professional
Modifier
Global
Typical Low
$79.43
Median
$125.89
Typical High
$218.78
Prevea360
Setting
Facility
Modifier
Global
Typical Low
$54.95
Median
$91.20
Typical High
$138.04
Prevea360
Setting
Professional
Modifier
Global
Typical Low
$63.10
Median
$109.65
Typical High
$117.49
Quartz
Setting
Professional
Modifier
Global
Typical Low
$112.20
Median
$165.96
Typical High
$263.03
Quartz
Setting
Facility
Modifier
Global
Typical Low
$63.10
Median
$229.09
Typical High
$478.63
Quartz
Setting
Professional
Modifier
Global
Typical Low
$45.71
Median
$165.96
Typical High
$616.60
Security Health
Setting
Professional
Modifier
Global
Typical Low
$87.10
Median
$100.00
Typical High
$102.33
United
Setting
Facility
Modifier
Global
Typical Low
$33.88
Median
$51.29
Typical High
$112.20
United
Setting
Professional
Modifier
Global
Typical Low
$36.31
Median
$54.95
Typical High
$95.50