L0458
Prosthetics & Orthotics
53 States
Tlso, triplanar control, modular segmented spinal system, two 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 xiphoid, 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
Short Desc
Tlso 2mod symphis-xipho pre
Coverage determined by local carrier discretion.
Added Date
2003-01-01
Effective From
2003-01-01
National Floor
$979.12
National Ceiling
$1,305.49
Fee Schedule Rates
Effective Jan 2026Official Medicare DMEPOS pricing for 2026.
| State | Modifier | Non-Rural | Rural |
|---|---|---|---|
|
AK
|
Base Rate |
$1,069.75
|
Same |
|
AL
|
Base Rate |
$1,101.98
|
Same |
|
AR
|
Base Rate |
$1,101.88
|
Same |
|
AZ
|
Base Rate |
$1,069.75
|
Same |
|
CA
|
Base Rate |
$1,069.75
|
Same |
|
CO
|
Base Rate |
$1,108.06
|
Same |
|
CT
|
Base Rate |
$1,069.75
|
Same |
|
DC
|
Base Rate |
$1,069.75
|
Same |
|
DE
|
Base Rate |
$1,069.75
|
Same |
|
FL
|
Base Rate |
$1,101.98
|
Same |
|
GA
|
Base Rate |
$1,101.98
|
Same |
|
HI
|
Base Rate |
$1,069.75
|
Same |
|
IA
|
Base Rate |
$1,090.65
|
Same |
|
ID
|
Base Rate |
$1,069.75
|
Same |
|
IL
|
Base Rate |
$1,096.06
|
Same |
|
IN
|
Base Rate |
$1,096.06
|
Same |
|
KS
|
Base Rate |
$1,090.65
|
Same |
|
KY
|
Base Rate |
$1,101.98
|
Same |
|
LA
|
Base Rate |
$1,101.88
|
Same |
|
MA
|
Base Rate |
$1,069.75
|
Same |
|
MD
|
Base Rate |
$1,069.75
|
Same |
|
ME
|
Base Rate |
$1,069.75
|
Same |
|
MI
|
Base Rate |
$1,096.06
|
Same |
|
MN
|
Base Rate |
$1,096.06
|
Same |
|
MO
|
Base Rate |
$1,090.65
|
Same |
|
MS
|
Base Rate |
$1,101.98
|
Same |
|
MT
|
Base Rate |
$1,108.06
|
Same |
|
NC
|
Base Rate |
$1,101.98
|
Same |
|
ND
|
Base Rate |
$1,108.06
|
Same |
|
NE
|
Base Rate |
$1,090.65
|
Same |
|
NH
|
Base Rate |
$1,069.75
|
Same |
|
NJ
|
Base Rate |
$1,069.75
|
Same |
|
NM
|
Base Rate |
$1,101.88
|
Same |
|
NV
|
Base Rate |
$1,069.75
|
Same |
|
NY
|
Base Rate |
$1,069.75
|
Same |
|
OH
|
Base Rate |
$1,096.06
|
Same |
|
OK
|
Base Rate |
$1,101.88
|
Same |
|
OR
|
Base Rate |
$1,069.75
|
Same |
|
PA
|
Base Rate |
$1,069.75
|
Same |
|
PR
|
Base Rate |
$1,176.76
|
Same |
|
RI
|
Base Rate |
$1,069.75
|
Same |
|
SC
|
Base Rate |
$1,101.98
|
Same |
|
SD
|
Base Rate |
$1,108.06
|
Same |
|
TN
|
Base Rate |
$1,101.98
|
Same |
|
TX
|
Base Rate |
$1,101.88
|
Same |
|
UT
|
Base Rate |
$1,108.06
|
Same |
|
VA
|
Base Rate |
$1,069.75
|
Same |
|
VI
|
Base Rate |
$1,176.76
|
Same |
|
VT
|
Base Rate |
$1,069.75
|
Same |
|
WA
|
Base Rate |
$1,069.75
|
Same |
|
WI
|
Base Rate |
$1,096.06
|
Same |
|
WV
|
Base Rate |
$1,069.75
|
Same |
|
WY
|
Base Rate |
$1,108.06
|
Same |