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Utah 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
$29.09 / $29.09 / $29.09
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.09 / $29.09 / $284.68
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 / $42.10 / $90.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$18.57 / $22.68 / $35.00
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$40.44 / $40.44 / $54.69
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.16 / $36.24 / $58.04
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$28.32 / $44.65 / $64.64