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Pennsylvania 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

Facilitymedian $355 · 10th–90th $135–$5250%20%10th90th$355Professionalmedian $170 · 10th–90th $135–$3090%20%40%10th90th$170$0.2$2.0$20.0$200.0$2.0K$20.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$134.90 / $524.81 / $524.81
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$134.90 / $169.82 / $251.19
Capital Blue Cross
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$5,011.87 / $8,511.38 / $77,624.71
Capital Blue Cross
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$331.13 / $331.13 / $331.13
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$229.09 / $229.09 / $338.84
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$165.96 / $165.96 / $229.09
Emblem Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$309.03 / $446.68 / $645.65
Geisinger
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$338.84 / $338.84 / $338.84
Geisinger
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$204.17 / $239.88 / $338.84
Martin's Point
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$134.90 / $134.90 / $134.90
Martin's Point
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$134.90 / $169.82 / $234.42
Oscar Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$0.60 / $478.63 / $660.69
UPMC Health Plan
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$75.86 / $239.88 / $316.23
UPMC Health Plan
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$75.86 / $239.88 / $323.59
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$151.36 / $416.87 / $478.63
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $165.96 / $338.84