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Nationwide rates for HCPCS L0484

Thoracic-lumbar-sacral orthosis (TLSO), triplanar control, two-piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated

Insurance Carrier	Facility/Professional	Low Price	Median Price	High Price
Aetna Facility/Professional Facility Modifier Low / Median / High Price $1,107.48 / $1,112.81 / $1,347.21	Facility	$1,107.48	$1,112.81	$1,347.21
Aetna Facility/Professional Professional Modifier Low / Median / High Price $929.15 / $1,148.65 / $1,620.32	Professional	$929.15	$1,148.65	$1,620.32
BCBS Facility/Professional Facility Modifier Low / Median / High Price $2,068.84 / $2,414.90 / $4,288.84	Facility	$2,068.84	$2,414.90	$4,288.84
BCBS Facility/Professional Professional Modifier Low / Median / High Price $1,188.46 / $1,247.18 / $1,694.78	Professional	$1,188.46	$1,247.18	$1,694.78
Cigna Facility/Professional Facility Modifier Low / Median / High Price $1,304.10 / $1,304.10 / $1,304.10	Facility	$1,304.10	$1,304.10	$1,304.10
Cigna Facility/Professional Professional Modifier Low / Median / High Price $952.00 / $1,304.10 / $1,343.23	Professional	$952.00	$1,304.10	$1,343.23
United Facility/Professional Professional Modifier Low / Median / High Price $832.36 / $1,010.30 / $1,571.29	Professional	$832.36	$1,010.30	$1,571.29

Nationwide rates for HCPCS L0484

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