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New Hampshire rates for HCPCS L0643

Lumbar-sacral orthosis (LSO), sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$111.80 / $111.80 / $134.16
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$56.38 / $83.22 / $111.80
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$122.50 / $122.50 / $145.21
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$110.53 / $111.80 / $111.80
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$128.79 / $128.79 / $128.79
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$94.02 / $94.02 / $128.79
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$154.19 / $154.19 / $475.94
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$59.47 / $95.02 / $126.71
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$107.37 / $118.11 / $150.32