go back

South Dakota 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
$236.81 / $236.81 / $236.81
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$213.05 / $235.52 / $236.81
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$227.96 / $227.96 / $373.07
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$395.25 / $395.25 / $494.06
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$235.52 / $398.03 / $1,593.03
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.26 / $219.61 / $371.97
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$310.20 / $373.07 / $584.29
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.54 / $378.32 / $712.92
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$287.37 / $336.46 / $399.94
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$118.93 / $171.88 / $286.47
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$332.37 / $332.37 / $332.37