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South Dakota rates for HCPCS L0636

Lumbar-sacral orthosis (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,135.03 / $1,135.03 / $1,135.03
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,135.03 / $1,246.01 / $1,282.81
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,030.36 / $1,030.36 / $2,181.83
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,893.75 / $2,181.83 / $2,367.19
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,355.45 / $2,167.94 / $8,437.43
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$723.14 / $1,196.14 / $2,175.44
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,814.14 / $2,181.83 / $3,063.51
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,786.91 / $2,212.53 / $4,169.41
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,565.29 / $1,832.58 / $2,178.31
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$623.59 / $989.53 / $1,495.18
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,943.81 / $1,943.81 / $1,943.81