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West Virginia 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
$84.24 / $84.24 / $84.24
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.53 / $84.24 / $171.49
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$86.79 / $170.03 / $233.66
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$86.79 / $93.46 / $309.57
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$52.17 / $52.17 / $155.57
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$38.08 / $52.17 / $598.16
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$94.18 / $103.82 / $171.49