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Michigan rates for HCPCS L0638

Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, 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, shoulder straps, pendulous abdomen design, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$907.53 / $907.53 / $907.53
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$753.84 / $907.53 / $907.53
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,405.25 / $4,792.18 / $8,728.14
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,509.67 / $1,589.13 / $2,145.33
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,008.15 / $1,032.93 / $1,038.52
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,271.30 / $1,271.30 / $1,271.30
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,115.23 / $1,115.23 / $1,115.23
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$814.12 / $1,115.23 / $1,842.38
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$907.53 / $1,148.38 / $1,148.38
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$853.53 / $1,148.38 / $1,668.58
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$999.56 / $1,175.96 / $1,352.35
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$554.53 / $746.26 / $1,137.36