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Wisconsin rates for HCPCS L1290

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$47.23 / $47.23 / $47.23
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$47.23 / $49.22 / $101.53
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$93.62 / $102.98 / $170.39
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$84.25 / $87.07 / $115.15
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$67.34 / $200.35 / $200.35
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$60.55 / $193.27 / $390.48
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$44.20 / $135.47 / $177.19
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$28.52 / $70.84 / $107.66
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.60 / $93.62 / $118.06
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$47.23 / $93.62 / $470.06
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.84 / $52.55 / $105.69
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $65.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$28.52 / $70.84 / $107.66
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.60 / $93.62 / $118.06
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$93.62 / $144.09 / $264.98
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$60.55 / $182.86 / $470.06
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$44.20 / $60.55 / $942.93
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$93.62 / $93.62 / $93.62
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$74.75 / $93.62 / $93.62
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$141.66 / $141.66 / $141.66
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$36.82 / $51.54 / $83.01