go back

Indiana rates for HCPCS L0628

Lumbar-sacral orthosis (LSO), flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$32.90 / $32.90 / $53.86
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$28.77 / $32.90 / $40.00
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$42.55 / $48.20 / $53.86
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.58 / $54.36 / $73.23
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$45.78 / $63.45 / $80.79
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$45.78 / $59.25 / $72.70
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$53.86 / $57.67 / $57.67
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$42.10 / $42.10 / $83.55
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.04 / $49.97 / $67.53