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Minnesota 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
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$36.84 / $36.84 / $216.85
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.47 / $36.84 / $36.84
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$147.78 / $147.78 / $147.78
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$40.00 / $40.00 / $90.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,009.05 / $1,009.05 / $1,009.05
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,009.05 / $1,009.05 / $1,009.05