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Montana 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
Professional
Modifier
Low / Median / High Price
$152.91 / $1,119.63 / $1,119.63
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$181.86 / $305.58 / $305.58
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$181.86 / $305.58 / $305.58
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$162.26 / $291.04 / $305.58
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$181.86 / $229.37 / $334.70
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$181.50 / $189.98 / $189.98
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$131.22 / $145.19 / $166.21