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Washington, DC 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
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$812.83 / $812.83 / $812.83
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$812.83 / $954.99 / $1,621.81
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,122.02 / $1,122.02 / $1,412.54
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,318.26 / $1,318.26 / $1,318.26
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$954.99 / $954.99 / $1,348.96
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,318.26 / $2,884.03 / $3,981.07
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,235.94 / $3,235.94 / $3,235.94
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$660.69 / $1,000.00 / $1,862.09