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New Hampshire 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
$239.42 / $239.42 / $287.30
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$120.72 / $178.21 / $239.42
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$262.27 / $262.27 / $310.91
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$236.66 / $239.42 / $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 / $1,019.19
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$101.86 / $203.47 / $271.33
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$229.94 / $252.93 / $321.92