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Utah 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
$98.06 / $98.06 / $98.06
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$98.06 / $113.61 / $959.87
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 / $227.96 / $234.80
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$155.94 / $251.52 / $326.97
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$301.68 / $336.46 / $336.46
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$191.58 / $241.18 / $361.77
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$116.70 / $150.54 / $178.40