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Hawaii rates for HCPCS L0455

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, off-the-shelf

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$144.61 / $144.61 / $144.61
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$324.01 / $324.01 / $324.01
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$278.10 / $278.10 / $426.14
HMSA
Facility/Professional
Professional
Modifier
Low / Median / High Price
$387.40 / $405.65 / $405.65
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$271.18 / $387.40 / $542.36
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$203.47 / $362.22 / $426.14
University Health Alliance
Facility/Professional
Professional
Modifier
Low / Median / High Price
$328.54 / $339.80 / $372.23