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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

Facilitymedian $200 · 10th–90th $166–$4790%20%10th90th$200Professionalmedian $166 · 10th–90th $78–$3630%10%20%10th90th$166$50.0$100.0$200.0$500.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$77.62 / $144.54 / $309.03
BCBS
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$331.13 / $331.13 / $331.13
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$275.42 / $363.08 / $363.08
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$275.42 / $363.08 / $363.08
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$165.96 / $194.98 / $478.63
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$165.96 / $194.98 / $478.63
Providence
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$114.82 / $275.42 / $398.11
Providence
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$79.43 / $218.78 / $363.08
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$186.21 / $199.53 / $234.42
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$173.78 / $186.21 / $295.12