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South Dakota rates for HCPCS L0484

Thoracic-lumbar-sacral orthosis (TLSO), triplanar control, two-piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated

Facilitymedian $1,660 · 10th–90th $1,514–$2,9510%20%40%10th90th$1,660Professionalmedian $1,660 · 10th–90th $891–$3,1620%10%10th90th$1,660$1.0K$2.0K$5.0K$10.0K

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
$1,513.56 / $1,513.56 / $1,513.56
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$891.25 / $1,513.56 / $1,737.80
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$1,318.26 / $1,318.26 / $2,290.87
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$2,570.40 / $2,570.40 / $3,162.28
Medica
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$1,548.82 / $2,238.72 / $4,466.84
Medica
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$912.01 / $1,548.82 / $12,022.64
Midlands
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$1,862.09 / $2,238.72 / $2,238.72
Midlands
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$2,290.87 / $2,290.87 / $2,290.87
Midlands
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$1,862.09 / $1,862.09 / $4,265.80
Sanford Health Plan
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$1,995.26 / $2,398.83 / $3,162.28
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$776.25 / $1,548.82 / $2,454.71
Wellmark
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$1,995.26 / $1,995.26 / $1,995.26