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Montana 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
Professional
Modifier
Low / Median / High Price
$78.03 / $1,176.75 / $1,176.75
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$333.60 / $333.60 / $333.60
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$278.10 / $359.49 / $359.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$278.10 / $359.49 / $359.49
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$137.74 / $278.10 / $359.49
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$196.07 / $261.42 / $359.49
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$175.30 / $186.23 / $310.39