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South Dakota rates for HCPCS L0642

Lumbar orthosis (LO), sagittal control, with rigid anterior and posterior panels, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$248.06 / $248.06 / $248.06
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$102.72 / $277.08 / $304.79
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$301.51 / $301.51 / $442.07
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$353.25 / $356.78 / $441.56
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$277.97 / $468.35 / $1,352.24
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$199.87 / $333.71 / $525.24
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$442.07 / $450.76 / $602.76
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$444.19 / $490.84 / $929.79
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$295.95 / $342.98 / $418.47
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.19 / $257.58 / $417.14
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$393.84 / $393.84 / $393.84