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Maine 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
$178.21 / $247.56 / $247.56
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$233.27 / $302.23 / $560.23
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$236.66 / $236.66 / $239.42
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$278.10 / $278.10 / $278.10
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$203.01 / $203.01 / $278.10
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$330.21 / $330.21 / $330.21
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.42 / $247.56 / $247.56
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$135.65 / $204.52 / $467.93