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Maine rates for HCPCS L0623

Sacroiliac orthosis (SO), 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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$72.00 / $126.31 / $126.31
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$118.75 / $153.86 / $285.20
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$39.00 / $39.00 / $39.00
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 / $52.17
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$168.49 / $168.49 / $168.49
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$72.00 / $126.31 / $126.31
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$69.20 / $117.73 / $300.11