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New Hampshire 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
$187.32 / $187.32 / $224.78
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$136.91 / $145.36 / $187.32
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$332.68 / $332.68 / $394.36
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$185.44 / $185.44 / $194.29
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$227.96 / $227.96 / $227.96
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$166.41 / $166.41 / $234.80
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$269.36 / $269.36 / $831.38
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$114.29 / $165.97 / $279.63
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$217.36 / $239.10 / $304.30