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LSO, Flexible, Off-the-Shelf

Pennsylvania 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

Rates data updated July 2026.

Facilitymedian $112 · 10th–90th $30$5250%10%20%10th90th$112Professionalmedian $40 · 10th–90th $30$650%20%10th90th$40$0.1$1.0$10.0$100.0$1.0K$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. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$29.51
Median
$29.51
Typical High
$112.20
Aetna
Setting
Professional
Modifier
Global
Typical Low
$28.84
Median
$33.88
Typical High
$60.26
Ambetter
Setting
Professional
Modifier
Global
Typical Low
$61.66
Median
$61.66
Typical High
$61.66
Capital Blue Cross
Setting
Facility
Modifier
Global
Typical Low
$5,011.87
Median
$8,511.38
Typical High
$77,624.71
Capital Blue Cross
Setting
Professional
Modifier
Global
Typical Low
$56.23
Median
$56.23
Typical High
$56.23
Cigna
Setting
Facility
Modifier
Global
Typical Low
$57.54
Median
$57.54
Typical High
$91.20
Cigna
Setting
Professional
Modifier
Global
Typical Low
$41.69
Median
$41.69
Typical High
$72.44
Emblem Health
Setting
Professional
Modifier
Global
Typical Low
$52.48
Median
$74.13
Typical High
$109.65
Geisinger
Setting
Facility
Modifier
Global
Typical Low
$57.54
Median
$57.54
Typical High
$57.54
Geisinger
Setting
Professional
Modifier
Global
Typical Low
$34.67
Median
$39.81
Typical High
$57.54
Martin's Point
Setting
Facility
Modifier
Global
Typical Low
$29.51
Median
$29.51
Typical High
$112.20
Martin's Point
Setting
Professional
Modifier
Global
Typical Low
$29.51
Median
$33.88
Typical High
$89.13
Oscar Health
Setting
Facility
Modifier
Global
Typical Low
$52.48
Median
$52.48
Typical High
$52.48
Oscar Health
Setting
Professional
Modifier
Global
Typical Low
$33.11
Median
$33.11
Typical High
$89.13
UPMC Health Plan
Setting
Facility
Modifier
Global
Typical Low
$151.36
Median
$354.81
Typical High
$575.44
UPMC Health Plan
Setting
Professional
Modifier
Global
Typical Low
$63.10
Median
$64.57
Typical High
$70.79
United
Setting
Facility
Modifier
Global
Typical Low
$41.69
Median
$100.00
Typical High
$100.00
United
Setting
Professional
Modifier
Global
Typical Low
$33.11
Median
$48.98
Typical High
$87.10