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Nebraska 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
$216.28 / $216.28 / $216.28
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$216.28 / $216.28 / $280.83
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$298.07 / $327.88 / $331.19
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$227.96 / $373.07 / $373.07
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$227.96 / $373.07 / $575.28
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$170.75 / $371.23 / $1,593.03
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$117.04 / $169.20 / $282.00
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$371.97 / $373.07 / $470.05
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$333.00 / $440.90 / $768.57
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$122.67 / $169.20 / $265.45