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West Virginia rates for HCPCS L0491

Thoracic-lumbar-sacral orthosis (TLSO), sagittal-coronal control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$466.60 / $466.60 / $466.60
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$434.96 / $446.56 / $466.60
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$604.70 / $1,219.27 / $1,580.53
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$587.04 / $651.22 / $1,116.36
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$576.88 / $576.88 / $1,090.21
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$421.12 / $576.88 / $4,437.87
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$936.84 / $936.84 / $936.84
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$345.65 / $457.84 / $750.96