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LSO, Flexible, Off-the-Shelf

Washington 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 $56 · 10th–90th $28$1350%10%10th90th$56Professionalmedian $33 · 10th–90th $23$1070%10%10th90th$33$1.0$5.0$20.0$100.0

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
$33.11
Median
$36.31
Typical High
$77.62
Aetna
Setting
Professional
Modifier
Global
Typical Low
$28.84
Median
$33.11
Typical High
$120.23
Asuris Northwest Health
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$53.70
Asuris Northwest Health
Setting
Professional
Modifier
Global
Typical Low
$24.55
Median
$28.84
Typical High
$70.79
Cigna
Setting
Facility
Modifier
Global
Typical Low
$57.54
Median
$57.54
Typical High
$57.54
Cigna
Setting
Professional
Modifier
Global
Typical Low
$41.69
Median
$41.69
Typical High
$57.54
Kaiser Permanente
Setting
Facility
Modifier
Global
Typical Low
$28.84
Median
$83.18
Typical High
$194.98
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$27.54
Median
$72.44
Typical High
$147.91
Molina
Setting
Professional
Modifier
Global
Typical Low
$67.61
Median
$75.86
Typical High
$83.18
Pacific Source
Setting
Facility
Modifier
Global
Typical Low
$28.18
Median
$41.69
Typical High
$77.62
Pacific Source
Setting
Professional
Modifier
Global
Typical Low
$28.18
Median
$36.31
Typical High
$81.28
Premera BCBS
Setting
Facility
Modifier
Global
Typical Low
$31.62
Median
$41.69
Typical High
$64.57
Premera BCBS
Setting
Professional
Modifier
Global
Typical Low
$22.91
Median
$22.91
Typical High
$41.69
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$28.18
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$24.55
Median
$28.84
Typical High
$70.79
United
Setting
Facility
Modifier
Global
Typical Low
$22.91
Median
$120.23
Typical High
$120.23
United
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$44.67
Typical High
$70.79
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$19.95
Median
$42.66
Typical High
$72.44