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Sacroiliac Orthosis, Flexible, Off-the-Shelf

Michigan rates for HCPCS L0621

Sacroiliac orthosis (SO), flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, off-the-shelf

Rates data updated July 2026.

Facilitymedian $102 · 10th–90th $43$2570%10%20%10th90th$102Professionalmedian $63 · 10th–90th $37$760%20%40%10th90th$63$0.1$0.5$2.0$10.0$50.0$200.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$42.66
Median
$42.66
Typical High
$42.66
Aetna
Setting
Professional
Modifier
Global
Typical Low
$33.88
Median
$42.66
Typical High
$63.10
BCBS
Setting
Facility
Modifier
Global
Typical Low
$83.18
Median
$190.55
Typical High
$363.08
BCBS
Setting
Professional
Modifier
Global
Typical Low
$63.10
Median
$63.10
Typical High
$66.07
CareSource
Setting
Facility
Modifier
Global
Typical Low
$48.98
Median
$48.98
Typical High
$48.98
Cigna
Setting
Facility
Modifier
Global
Typical Low
$67.61
Median
$67.61
Typical High
$77.62
Cigna
Setting
Professional
Modifier
Global
Typical Low
$48.98
Median
$67.61
Typical High
$117.49
Health Alliance Plan
Setting
Facility
Modifier
Global
Typical Low
$41.69
Median
$199.53
Typical High
$218.78
Health Alliance Plan
Setting
Professional
Modifier
Global
Typical Low
$41.69
Median
$75.86
Typical High
$100.00
Priority Health
Setting
Professional
Modifier
Global
Typical Low
$58.88
Median
$87.10
Typical High
$128.82
United
Setting
Facility
Modifier
Global
Typical Low
$35.48
Median
$64.57
Typical High
$128.82
United
Setting
Professional
Modifier
Global
Typical Low
$34.67
Median
$50.12
Typical High
$79.43