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LSO, Flexible, Off-the-Shelf

Wisconsin 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 $55 · 10th–90th $54$1120%50%10th90th$55Professionalmedian $51 · 10th–90th $34$910%20%40%10th90th$51$0.1$0.5$2.0$10.0$50.0$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. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$33.88
Median
$33.88
Typical High
$33.88
Aetna
Setting
Professional
Modifier
Global
Typical Low
$33.11
Median
$33.88
Typical High
$57.54
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$54.95
Median
$54.95
Typical High
$91.20
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$51.29
Median
$51.29
Typical High
$61.66
Cigna
Setting
Facility
Modifier
Global
Typical Low
$57.54
Median
$239.88
Typical High
$323.59
Cigna
Setting
Professional
Modifier
Global
Typical Low
$41.69
Median
$91.20
Typical High
$102.33
DeanCare
Setting
Facility
Modifier
Global
Typical Low
$33.88
Median
$53.70
Typical High
$83.18
DeanCare
Setting
Professional
Modifier
Global
Typical Low
$53.70
Median
$114.82
Typical High
$158.49
Medica
Setting
Facility
Modifier
Global
Typical Low
$33.88
Median
$61.66
Typical High
$275.42
Medica
Setting
Professional
Modifier
Global
Typical Low
$44.67
Median
$52.48
Typical High
$97.72
Molina
Setting
Professional
Modifier
Global
Typical Low
$50.12
Median
$63.10
Typical High
$85.11
Network Health
Setting
Facility
Modifier
Global
Typical Low
$162.18
Median
$162.18
Typical High
$162.18
Network Health
Setting
Professional
Modifier
Global
Typical Low
$51.29
Median
$77.62
Typical High
$134.90
Prevea360
Setting
Facility
Modifier
Global
Typical Low
$33.88
Median
$53.70
Typical High
$83.18
Prevea360
Setting
Professional
Modifier
Global
Typical Low
$28.18
Median
$53.70
Typical High
$57.54
Quartz
Setting
Professional
Modifier
Global
Typical Low
$44.67
Median
$66.07
Typical High
$125.89
Quartz
Setting
Facility
Modifier
Global
Typical Low
$57.54
Median
$112.20
Typical High
$281.84
Quartz
Setting
Professional
Modifier
Global
Typical Low
$41.69
Median
$100.00
Typical High
$426.58
Security Health
Setting
Professional
Modifier
Global
Typical Low
$81.28
Median
$93.33
Typical High
$95.50
United
Setting
Facility
Modifier
Global
Typical Low
$30.20
Median
$50.12
Typical High
$69.18
United
Setting
Professional
Modifier
Global
Typical Low
$33.88
Median
$50.12
Typical High
$83.18