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Pennsylvania rates for HCPCS L0621

Sacroiliac Orthosis Flexible Provides Pelvic- Sacral Support Reduces Motion About The Sacro- Iliac Joint Includes Straps Closures May Include Pendulous Abdomen Design Prefabricated Off-The-Shelf (Revised 01/01/14)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$33.06 / $33.06 / $127.94
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$33.06 / $38.68 / $62.39
Ambetter
Facility/Professional
Professional
Modifier
Low / Median / High Price
$66.89 / $66.89 / $66.89
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,000.00 / $8,639.91 / $79,506.39
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$57.85 / $65.36 / $65.36
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$65.36 / $67.20 / $77.70
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.06 / $49.06 / $83.87
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.67 / $65.36 / $88.50
Highmark BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.09 / $62.09 / $62.09
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$33.06 / $33.06 / $127.94
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$33.06 / $38.21 / $81.09
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$39.00 / $51.20 / $160.69
Priority Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$65.36 / $67.20 / $77.70
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.06 / $49.06 / $84.75
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$72.31 / $72.31 / $74.28
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.76 / $72.31 / $74.28
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$105.88 / $124.56 / $149.47
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$39.22 / $51.92 / $90.77