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Illinois rates for HCPCS L0628

Lumbar-Sacral Orthosis Flexible Provides Lumbo-Sacral Support Posterior Extends From Sacro- Coccygeal Juntion To T-9 Vertebra Produces Intra-Cavitary Pressure To Reduce Load On The Inter- Vertebral Discs Includes Straps Closures May Include Stays Shoulder Straps Pendulous Abdomen Design Prefabricated Off-The-Shelf (Revised 01/01/14)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$34.17 / $34.17 / $53.86
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.09 / $34.79 / $54.24
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$132.43 / $275.88 / $636.32
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.15 / $40.93 / $40.93
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$57.67 / $57.67 / $90.22
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$42.10 / $42.10 / $90.00
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.86 / $97.83 / $125.75
Hally Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.02 / $70.02 / $70.02
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$68.34 / $97.64 / $102.52
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$34.72 / $50.42 / $86.55