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Michigan 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
Facility
Modifier
Low / Median / High Price
$79.95 / $79.95 / $79.95
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.53 / $79.95 / $79.95
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$171.56 / $341.82 / $622.55
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$107.68 / $113.35 / $153.02
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$73.68 / $73.68 / $86.79
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$90.68 / $90.68 / $90.68
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$52.17 / $52.17 / $52.17
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$52.17 / $52.17 / $177.30
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$21.70 / $21.70 / $79.95
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21.70 / $79.95 / $136.02
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$109.05 / $128.30 / $147.54
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.64 / $105.43 / $175.72