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Idaho 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
$131.09 / $291.31 / $291.31
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$208.66 / $227.96 / $227.96
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$166.41 / $227.96 / $234.80
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$98.06 / $234.34 / $332.68
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$299.41 / $316.05 / $332.68
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $245.51 / $292.39
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$291.31 / $324.88 / $487.32
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$232.88 / $241.18 / $349.31
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$140.44 / $150.54 / $234.07