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Sacroiliac Orthosis, Flexible, Off-the-Shelf

Minnesota 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 $158 · 10th–90th $72$6030%10%20%10th90th$158Professionalmedian $89 · 10th–90th $56$910%50%10th90th$89$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
$56.23
Median
$56.23
Typical High
$56.23
Aetna
Setting
Professional
Modifier
Global
Typical Low
$33.88
Median
$56.23
Typical High
$64.57
BCBS
Setting
Facility
Modifier
Global
Typical Low
$87.10
Median
$89.13
Typical High
$128.82
BCBS
Setting
Professional
Modifier
Global
Typical Low
$70.79
Median
$89.13
Typical High
$89.13
Cigna
Setting
Facility
Modifier
Global
Typical Low
$165.96
Median
$275.42
Typical High
$758.58
Cigna
Setting
Professional
Modifier
Global
Typical Low
$85.11
Median
$97.72
Typical High
$107.15
Health Partners
Setting
Facility
Modifier
Global
Typical Low
$213.80
Median
$302.00
Typical High
$602.56
Health Partners
Setting
Professional
Modifier
Global
Typical Low
$85.11
Median
$85.11
Typical High
$114.82
Medica
Setting
Facility
Modifier
Global
Typical Low
$47.86
Median
$72.44
Typical High
$323.59
Medica
Setting
Professional
Modifier
Global
Typical Low
$34.67
Median
$51.29
Typical High
$104.71
United
Setting
Facility
Modifier
Global
Typical Low
$0.83
Median
$51.29
Typical High
$151.36
United
Setting
Professional
Modifier
Global
Typical Low
$34.67
Median
$60.26
Typical High
$112.20