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Hawaii 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
$113.25 / $113.25 / $113.25
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$264.29 / $264.29 / $264.29
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$227.96 / $227.96 / $365.95
HMSA
Facility/Professional
Professional
Modifier
Low / Median / High Price
$332.68 / $348.36 / $348.36
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$199.61 / $332.68 / $465.75
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$231.84 / $264.29 / $365.95
University Health Alliance
Facility/Professional
Professional
Modifier
Low / Median / High Price
$267.99 / $277.17 / $316.64