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Utah 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
$457.09 / $457.09 / $457.09
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$457.09 / $851.14 / $6,760.83
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,122.02 / $1,122.02 / $1,122.02
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$812.83 / $812.83 / $1,202.26
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $1,174.90 / $1,513.56
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,202.26 / $1,412.54 / $2,454.71
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$891.25 / $1,148.15 / $1,659.59
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,445.44 / $1,621.81 / $1,621.81
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,174.90 / $1,621.81 / $1,905.46
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$588.84 / $707.95 / $933.25
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$549.54 / $707.95 / $1,023.29