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Montana rates for HCPCS L0633

Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$132.88 / $972.99 / $972.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$192.91 / $367.48 / $367.48
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$192.91 / $367.48 / $367.48
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$172.12 / $349.98 / $367.48
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$192.91 / $275.81 / $367.75
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$139.21 / $154.02 / $176.31