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Massachusetts 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
Facility
Modifier
Low / Median / High Price
$145.36 / $145.36 / $145.36
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$145.36 / $160.22 / $213.05
AllWays Health Partners
Facility/Professional
Facility
Modifier
Low / Median / High Price
$259.64 / $860.22 / $1,593.03
AllWays Health Partners
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.91 / $247.11 / $324.88
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$217.83 / $217.83 / $224.97
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$227.96 / $227.96 / $244.51
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$166.41 / $227.96 / $395.25
Fallon Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$83.43 / $4,618.00 / $9,239.00
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$269.36 / $269.36 / $282.83
Health New England
Facility/Professional
Professional
Modifier
Low / Median / High Price
$245.63 / $245.63 / $245.63
Mass General Brigham
Facility/Professional
Facility
Modifier
Low / Median / High Price
$691.86 / $1,593.03 / $1,593.03
Mass General Brigham
Facility/Professional
Professional
Modifier
Low / Median / High Price
$126.58 / $165.97 / $324.88
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$129.94 / $177.82 / $324.88