go back

Montana 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
$39.77 / $600.41 / $600.41
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$52.17 / $183.28 / $183.28
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$52.17 / $183.28 / $183.28
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$52.17 / $87.65 / $183.28
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$52.17 / $99.91 / $183.28
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$94.18 / $95.03 / $156.97