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Vermont 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
Professional
Modifier
Low / Median / High Price
$162.34 / $162.34 / $187.32
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$227.96 / $227.96 / $244.51
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$166.41 / $189.78 / $234.80
MVP Health Care
Facility/Professional
Facility
Modifier
Low / Median / High Price
$227.96 / $227.96 / $244.51
MVP Health Care
Facility/Professional
Professional
Modifier
Low / Median / High Price
$166.41 / $227.96 / $234.80
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$110.65 / $250.01 / $276.62