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Utah rates for HCPCS L0642

Lumbar orthosis (LO), sagittal control, with rigid anterior and posterior panels, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$190.55 / $190.55 / $190.55
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$117.49 / $251.19 / $602.56
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$302.00 / $302.00 / $302.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$218.78 / $218.78 / $323.59
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$34.67 / $112.20 / $151.36
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$218.78 / $257.04 / $457.09
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$147.91 / $147.91 / $288.40
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$204.17 / $208.93 / $416.87
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$190.55 / $208.93 / $309.03
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$181.97 / $218.78 / $234.42
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.70 / $213.80 / $281.84