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LSO, Flexible, Off-the-Shelf

South Dakota 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 $76 · 10th–90th $56$1260%10%20%10th90th$76Professionalmedian $62 · 10th–90th $46$890%10%10th90th$62$10.0$20.0$50.0$100.0$200.0

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
Setting
Facility
Modifier
Global
Typical Low
$74.13
Median
$74.13
Typical High
$74.13
Aetna
Setting
Professional
Modifier
Global
Typical Low
$45.71
Median
$52.48
Typical High
$56.23
Cigna
Setting
Facility
Modifier
Global
Typical Low
$57.54
Median
$57.54
Typical High
$93.33
Cigna
Setting
Professional
Modifier
Global
Typical Low
$72.44
Median
$72.44
Typical High
$89.13
Medica
Setting
Facility
Modifier
Global
Typical Low
$56.23
Median
$85.11
Typical High
$154.88
Medica
Setting
Professional
Modifier
Global
Typical Low
$40.74
Median
$64.57
Typical High
$416.87
Midlands
Setting
Professional
Modifier
Global
Typical Low
$91.20
Median
$91.20
Typical High
$91.20
Midlands
Setting
Facility
Modifier
Global
Typical Low
$93.33
Median
$93.33
Typical High
$93.33
Midlands
Setting
Professional
Modifier
Global
Typical Low
$91.20
Median
$91.20
Typical High
$181.97
Sanford Health Plan
Setting
Professional
Modifier
Global
Typical Low
$61.66
Median
$69.18
Typical High
$85.11
United
Setting
Facility
Modifier
Global
Typical Low
$50.12
Median
$52.48
Typical High
$75.86
United
Setting
Professional
Modifier
Global
Typical Low
$10.96
Median
$64.57
Typical High
$85.11
Wellmark
Setting
Professional
Modifier
Global
Typical Low
$81.28
Median
$81.28
Typical High
$81.28