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Nebraska 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
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $50.00 / $50.00
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$40.00 / $40.00 / $90.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.00 / $40.00 / $40.00
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$690.57 / $690.57 / $690.57
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$599.65 / $599.65 / $690.57