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Montana rates for HCPCS L0636

Lumbar-sacral orthosis (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, 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, anterior panel, pendulous abdomen design, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$838.71 / $6,141.28 / $6,141.28
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,030.36 / $1,970.39 / $1,970.39
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,030.36 / $1,970.39 / $1,970.39
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$890.02 / $1,876.56 / $1,970.39
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,410.24 / $1,511.63 / $1,971.82
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$719.81 / $796.42 / $1,327.36