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Montana rates for HCPCS L0462

Thoracic-lumbar-sacral orthosis (TLSO), triplanar control, modular segmented spinal system, three 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 sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse 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
Professional
Modifier
Low / Median / High Price
$578.57 / $4,236.45 / $4,236.45
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,038.85 / $1,596.93 / $1,596.93
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,038.85 / $1,298.64 / $1,596.93
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$749.26 / $1,520.89 / $1,596.93
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,038.85 / $1,198.57 / $1,598.09
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$605.97 / $670.46 / $1,025.98