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Vermont 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
$120.23 / $181.97 / $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
MVP Health Care
Facility/Professional
Professional
Modifier
Low / Median / High Price
$223.87 / $263.03 / $316.23
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$186.21 / $186.21 / $234.42
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$141.25 / $316.23 / $630.96