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LSO, Flexible, Custom Fabricated

Wisconsin rates for HCPCS L0629

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, custom fabricated

Rates data updated July 2026.

Facilitymedian $174 · 10th–90th $162$2630%50%10th90th$174Professionalmedian $174 · 10th–90th $174$2040%50%90th$174$50.0$100.0$200.0$500.0

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
$173.78
Median
$173.78
Typical High
$173.78
Aetna
Setting
Professional
Modifier
Global
Typical Low
$173.78
Median
$173.78
Typical High
$173.78
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$204.17
Typical High
$204.17
Cigna
Setting
Facility
Modifier
Global
Typical Low
$263.03
Median
$263.03
Typical High
$263.03
Cigna
Setting
Professional
Modifier
Global
Typical Low
$190.55
Median
$190.55
Typical High
$263.03
DeanCare
Setting
Facility
Modifier
Global
Typical Low
$173.78
Median
$173.78
Typical High
$309.03
DeanCare
Setting
Professional
Modifier
Global
Typical Low
$338.84
Median
$380.19
Typical High
$489.78
Medica
Setting
Facility
Modifier
Global
Typical Low
$162.18
Median
$173.78
Typical High
$263.03
Medica
Setting
Professional
Modifier
Global
Typical Low
$616.60
Median
$616.60
Typical High
$616.60
Molina
Setting
Professional
Modifier
Global
Typical Low
$50.12
Median
$58.88
Typical High
$70.79
Prevea360
Setting
Facility
Modifier
Global
Typical Low
$173.78
Median
$173.78
Typical High
$309.03
Quartz
Setting
Professional
Modifier
Global
Typical Low
$134.90
Median
$147.91
Typical High
$190.55
Quartz
Setting
Facility
Modifier
Global
Typical Low
$154.88
Median
$162.18
Typical High
$263.03
Quartz
Setting
Professional
Modifier
Global
Typical Low
$190.55
Median
$190.55
Typical High
$263.03
United
Setting
Facility
Modifier
Global
Typical Low
$251.19
Median
$251.19
Typical High
$251.19
United
Setting
Professional
Modifier
Global
Typical Low
$616.60
Median
$616.60
Typical High
$616.60