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Missouri rates for HCPCS L0622

Sacroiliac orthosis (SO), flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$182.08 / $182.08 / $242.57
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$165.52 / $188.70 / $288.01
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$347.81 / $365.20 / $1,605.49
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$169.72 / $177.26 / $281.39
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$181.86 / $181.86 / $181.86
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$132.76 / $132.76 / $187.32
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$161.71 / $280.30 / $1,549.83
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$120.30 / $173.51 / $422.75
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$111.88 / $145.19 / $278.25
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$120.30 / $171.97 / $251.45