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Indiana 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
$136.01 / $136.01 / $222.65
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$118.89 / $136.01 / $165.36
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$175.89 / $199.27 / $222.65
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$215.04 / $268.80 / $362.12
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$189.25 / $262.27 / $333.98
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$189.25 / $244.92 / $300.58
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$222.65 / $278.10 / $278.10
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$203.01 / $278.10 / $310.27
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$124.16 / $201.75 / $292.17