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South Dakota rates for HCPCS L0455

Thoracic-lumbar-sacral orthosis (TLSO), flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, off-the-shelf

Facilitymedian $240 · 10th–90th $209–$4680%20%10th90th$240Professionalmedian $234 · 10th–90th $138–$3720%10%20%10th90th$234$50.0$100.0$200.0$500.0$1.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Small sample — interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$208.93 / $208.93 / $208.93
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$134.90 / $208.93 / $234.42
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$275.42 / $275.42 / $380.19
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$295.12 / $302.00 / $371.54
Medica
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$234.42 / $354.81 / $645.65
Medica
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$169.82 / $281.84 / $1,737.80
Midlands
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$371.54 / $371.54 / $380.19
Midlands
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$380.19 / $380.19 / $380.19
Midlands
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$380.19 / $380.19 / $758.58
Sanford Health Plan
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$257.04 / $288.40 / $354.81
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$44.67 / $263.03 / $338.84
Wellmark
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$331.13 / $331.13 / $331.13