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West Virginia rates for HCPCS L0454

Thoracic-lumbar-sacral orthosis (TLSO), flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$210.71 / $210.71 / $210.71
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$196.42 / $201.66 / $210.71
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$273.08 / $550.60 / $713.74
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$265.10 / $294.10 / $504.17
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$233.26 / $233.26 / $492.35
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$170.28 / $170.28 / $2,004.11
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$156.09 / $210.19 / $354.28