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Nebraska rates for HCPCS L0455

Thoracic-lumbar-sacral orthosis (TLSO), flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, off-the-shelf

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$191.74 / $191.74 / $191.74
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$191.74 / $191.74 / $248.98
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$224.69 / $247.15 / $249.65
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$278.10 / $372.96 / $372.96
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$278.10 / $372.66 / $705.31
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$172.57 / $329.11 / $1,140.66
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$131.47 / $207.44 / $325.45
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$372.96 / $374.74 / $576.29
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$374.74 / $492.57 / $784.41
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$131.47 / $207.44 / $292.17