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Maine 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
$159.01 / $201.93 / $201.93
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$295.89 / $383.35 / $710.60
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$185.44 / $194.29 / $194.29
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 / $166.41 / $227.96
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$269.36 / $269.36 / $269.36
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$187.32 / $201.93 / $201.93
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$117.04 / $187.26 / $381.68