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Montana rates for HCPCS L4000

Replace girdle for spinal orthosis (cervical-thoracic-lumbar-sacral orthosis (CTLSO) or spinal orthosis SO)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$754.68 / $5,526.01 / $5,526.01
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$897.58 / $1,710.54 / $1,710.54
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$897.58 / $1,710.54 / $1,710.54
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$800.86 / $1,629.09 / $1,710.54
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,283.83 / $1,312.30 / $1,783.11
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$647.70 / $716.63 / $1,096.64