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Arizona rates for HCPCS L0623

Sacroiliac Orthosis Provides Pelvic-Sacral Support With Rigid Or Semi-Rigid Panels Over The Sacrum And Abdomen Reduces Motion About The Sacroiliac Joint Includes Straps Closures May Include Pendulous Abdomen Design Prefabricated Off-The-Shelf (Revised 01/01/14)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.08 / $50.40 / $144.16
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$33.06 / $119.41 / $215.90
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$82.64 / $110.18 / $150.13
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$52.17 / $52.17 / $52.17
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$38.08 / $38.08 / $151.88
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$28.81 / $55.40 / $580.79
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$86.33 / $95.03 / $156.97
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$87.11 / $95.03 / $156.97