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Arizona rates for HCPCS L0490

Thoracic-lumbar-sacral orthosis (TLSO), sagittal-coronal control, one-piece rigid plastic shell, with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$133.07 / $169.60 / $300.05
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$79.84 / $288.42 / $521.46
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$199.61 / $266.14 / $362.62
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$227.96 / $227.96 / $227.96
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$166.41 / $166.41 / $395.25
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$98.06 / $231.84 / $1,593.03
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.15 / $151.90 / $228.81
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.29 / $151.90 / $217.91