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Pennsylvania rates for HCPCS L1200

Thoracic-lumbar-sacral orthosis (TLSO), inclusive of furnishing initial orthosis only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$726.45 / $4,923.63 / $4,923.63
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$690.78 / $834.65 / $1,158.07
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,000.00 / $8,639.91 / $79,506.39
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,344.09 / $1,765.16 / $1,765.16
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,184.20 / $1,184.20 / $1,765.16
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$864.47 / $864.47 / $1,545.64
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,623.95 / $1,765.16 / $3,353.80
Highmark BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$8,118.95 / $8,118.95 / $8,158.22
Highmark BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,235.60 / $1,395.59 / $1,412.13
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,123.36 / $2,123.36 / $4,923.63
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$690.77 / $850.10 / $1,344.09
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,195.59 / $2,298.00 / $3,477.70
Priority Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,184.20 / $1,184.20 / $1,765.16
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$864.47 / $864.47 / $2,499.75
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,262.03 / $1,680.11 / $1,680.11
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,262.03 / $1,680.11 / $2,052.23
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$728.87 / $884.34 / $1,591.85