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Utah 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
$514.15 / $514.15 / $514.15
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$514.15 / $725.55 / $6,141.28
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,030.36 / $1,030.36 / $1,030.36
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$752.17 / $752.17 / $1,893.75
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$849.36 / $1,369.94 / $1,780.92
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,643.18 / $1,832.58 / $1,832.58
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,043.53 / $1,313.59 / $1,970.39
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$623.59 / $796.42 / $1,019.74