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California rates for HCPCS L0624

Sacroiliac orthosis (SO), provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$40.00 / $40.00 / $40.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.00 / $40.00 / $40.00
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$90.93 / $109.52 / $289.55
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$58.35 / $126.41 / $126.41
Blue Shield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,452.60 / $2,041.56 / $2,996.01
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$211.11 / $211.11 / $211.11
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$393.93 / $638.07 / $801.00
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$90.00 / $90.00 / $100.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.00 / $60.00 / $85.00
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$40.00 / $40.00 / $40.00
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.00 / $2,250,000.00 / $2,400,000.00