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Montana rates for HCPCS L0643

Lumbar-sacral orthosis (LSO), sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$36.44 / $549.51 / $549.51
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$128.79 / $168.07 / $168.07
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$128.79 / $168.07 / $168.07
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.33 / $128.79 / $168.07
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$91.64 / $122.18 / $168.07
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$81.88 / $86.98 / $137.94