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Illinois 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
Facility
Modifier
Low / Median / High Price
$141.25 / $141.25 / $229.09
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$134.90 / $158.49 / $234.42
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$416.87 / $562.34 / $2,691.53
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$147.91 / $169.82 / $169.82
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$275.42 / $275.42 / $380.19
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$204.17 / $204.17 / $295.12
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$223.87 / $389.05 / $512.86
Hally Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$288.40 / $288.40 / $288.40
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$177.83 / $177.83 / $257.04
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$162.18 / $177.83 / $501.19
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.04 / $208.93 / $323.59