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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

Facilitymedian $174 · 10th–90th $98–$3470%20%40%10th90th$174Professionalmedian $234 · 10th–90th $98–$1,4450%5%10%10th90th$234$50.0$100.0$200.0$500.0$1.0K

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
$97.72 / $97.72 / $97.72
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$97.72 / $190.55 / $1,445.44
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$229.09 / $229.09 / $229.09
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$165.96 / $165.96 / $229.09
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$60.26 / $251.19 / $323.59
Regence BlueShield
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$331.13 / $346.74 / $346.74
Regence BlueShield
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$239.88 / $245.47 / $371.54
Select Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$331.13 / $346.74 / $354.81
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$245.47 / $354.81 / $407.38
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$125.89 / $151.36 / $173.78
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$120.23 / $151.36 / $257.04