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Minnesota 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
Facility
Modifier
Low / Median / High Price
$106.62 / $106.62 / $106.62
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$72.00 / $106.62 / $156.84
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$150.55 / $160.47 / $498.22
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.69 / $164.71 / $173.38
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$52.17 / $401.41 / $1,114.86
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$151.88 / $160.99 / $192.88
Health Partners
Facility/Professional
Facility
Modifier
Low / Median / High Price
$238.31 / $385.13 / $877.85
Health Partners
Facility/Professional
Professional
Modifier
Low / Median / High Price
$151.88 / $151.88 / $155.19
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$29.67 / $130.91 / $580.79
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.35 / $106.27 / $395.88
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.35 / $106.11 / $214.13