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South Dakota rates for HCPCS L0649

Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid posterior frame/panel(s), 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, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$173.05 / $173.05 / $173.05
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$156.19 / $173.05 / $193.33
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$211.82 / $211.82 / $308.39
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$246.38 / $248.84 / $307.97
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$193.91 / $326.73 / $943.35
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$139.43 / $232.81 / $366.41
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$308.39 / $314.44 / $420.47
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$309.87 / $342.40 / $648.61
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$206.46 / $239.26 / $291.93
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$37.10 / $179.69 / $291.01
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$274.74 / $274.74 / $274.74