go back

Utah rates for HCPCS L0643

Lumbar-sacral orthosis (LSO), sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.86 / $75.86 / $75.86
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$44.67 / $75.86 / $234.42
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$128.82 / $128.82 / $128.82
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$93.33 / $93.33 / $138.04
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $43.65 / $60.26
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$87.10 / $102.33 / $181.97
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$57.54 / $57.54 / $114.82
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$81.28 / $83.18 / $162.18
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$74.13 / $83.18 / $123.03
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$72.44 / $87.10 / $93.33
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$20.89 / $83.18 / $109.65