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Montana 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 / $959.87 / $959.87
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$227.96 / $361.77 / $361.77
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$227.96 / $294.18 / $361.77
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$169.75 / $344.54 / $361.77
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$227.96 / $271.51 / $362.02
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.29 / $151.90 / $173.88