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South Dakota 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
$1,104.16 / $1,104.16 / $1,104.16
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$993.37 / $1,098.24 / $1,104.16
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,115.23 / $1,115.23 / $1,739.43
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,842.38 / $1,842.38 / $2,302.96
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,098.24 / $1,856.03 / $7,399.97
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$640.03 / $1,024.05 / $1,734.34
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,446.31 / $1,739.43 / $2,724.24
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,424.60 / $1,763.92 / $3,324.03
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,340.08 / $1,568.91 / $1,864.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$554.53 / $801.50 / $1,335.83
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,549.67 / $1,549.67 / $1,549.67