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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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$136.91 / $136.91 / $529.88
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$130.19 / $151.47 / $184.00
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,000.00 / $8,639.91 / $79,506.39
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$253.32 / $332.68 / $332.68
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$227.96 / $227.96 / $332.68
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$166.41 / $166.41 / $291.31
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$306.07 / $332.68 / $632.09
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$136.91 / $136.91 / $529.88
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$130.19 / $157.31 / $216.28
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$412.50 / $474.40 / $655.40
Priority Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$227.96 / $227.96 / $332.68
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$166.41 / $166.41 / $395.25
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$237.85 / $316.64 / $316.64
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$237.85 / $316.64 / $324.39
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$126.58 / $165.97 / $300.01