go back

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
$117.49 / $151.36 / $245.47
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$263.03 / $316.23 / $354.81
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.88 / $239.88 / $239.88
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$275.42 / $275.42 / $275.42
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$204.17 / $204.17 / $275.42
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$229.09 / $229.09 / $275.42
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$120.23 / $199.53 / $398.11
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$117.49 / $186.21 / $186.21
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$134.90 / $229.09 / $354.81