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Michigan 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
$37.96 / $37.96 / $37.96
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$28.77 / $37.96 / $53.45
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$81.52 / $162.41 / $295.82
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.17 / $53.86 / $72.70
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$35.01 / $35.01 / $41.24
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$43.09 / $43.09 / $43.09
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$57.67 / $57.67 / $57.67
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$42.10 / $72.00 / $90.00
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$37.96 / $73.03 / $73.03
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$37.96 / $60.70 / $80.52
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.91 / $60.87 / $70.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$33.61 / $47.45 / $72.33