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

Facilitymedian $257 · 10th–90th $234–$4270%20%40%10th90th$257Professionalmedian $240 · 10th–90th $151–$4900%20%10th90th$240$200.0$500.0$1.0K$2.0K

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$234.42 / $234.42 / $234.42
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$151.36 / $234.42 / $288.40
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$229.09 / $229.09 / $380.19
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$398.11 / $398.11 / $489.78
Medica
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$257.04 / $338.84 / $645.65
Medica
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$138.04 / $229.09 / $4,168.69
Midlands
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$309.03 / $371.54 / $371.54
Midlands
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$380.19 / $380.19 / $380.19
Midlands
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$309.03 / $309.03 / $616.60
Sanford Health Plan
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$288.40 / $346.74 / $457.09
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$120.23 / $234.42 / $380.19
Wellmark
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$331.13 / $331.13 / $331.13