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Utah 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

Facilitymedian $166 · 10th–90th $158–$2240%50%10th90th$166Professionalmedian $178 · 10th–90th $95–$5010%10%10th90th$178$50.0$100.0$200.0$500.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Small sample — interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$158.49 / $158.49 / $158.49
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$67.61 / $208.93 / $501.19
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$275.42 / $275.42 / $275.42
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$204.17 / $204.17 / $275.42
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$34.67 / $93.33 / $125.89
Regence BlueShield
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$165.96 / $173.78 / $223.87
Regence BlueShield
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$123.03 / $123.03 / $245.47
Select Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$173.78 / $177.83 / $346.74
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$158.49 / $177.83 / $263.03
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$154.88 / $186.21 / $199.53
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$44.67 / $177.83 / $263.03