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Washington 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 $224 · 10th–90th $112–$6460%20%10th90th$224Professionalmedian $170 · 10th–90th $98–$3630%10%10th90th$170$5.0$20.0$100.0$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. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$134.90 / $134.90 / $323.59
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$120.23 / $165.96 / $288.40
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$112.20 / $112.20 / $338.84
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$100.00 / $104.71 / $288.40
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
Kaiser Permanente
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$112.20 / $398.11 / $831.76
Kaiser Permanente
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$112.20 / $331.13 / $645.65
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$251.19 / $316.23 / $346.74
Pacific Source
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$114.82 / $114.82 / $323.59
Premera BCBS
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$128.82 / $173.78 / $288.40
Premera BCBS
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$95.50 / $95.50 / $173.78
Regence BlueShield
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$112.20 / $112.20 / $181.97
Regence BlueShield
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$100.00 / $117.49 / $288.40
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$95.50 / $501.19 / $501.19
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$173.78 / $186.21 / $309.03
Wellpoint
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$83.18 / $100.00 / $288.40