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Sacroiliac Orthosis, Flexible, Off-the-Shelf

New Hampshire 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 $79 · 10th–90th $69$930%20%10th90th$79Professionalmedian $65 · 10th–90th $48$830%50%10th90th$65$50.0$100.0$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
$69.18
Median
$69.18
Typical High
$83.18
Aetna
Setting
Professional
Modifier
Global
Typical Low
$33.11
Median
$69.18
Typical High
$83.18
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$75.86
Median
$81.28
Typical High
$93.33
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$63.10
Median
$63.10
Typical High
$63.10
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
$48.98
Typical High
$67.61
Harvard Pilgrim
Setting
Professional
Modifier
Global
Typical Low
$64.57
Median
$64.57
Typical High
$120.23
United
Setting
Facility
Modifier
Global
Typical Low
$31.62
Median
$51.29
Typical High
$64.57
United
Setting
Professional
Modifier
Global
Typical Low
$38.90
Median
$64.57
Typical High
$91.20
Well Sense
Setting
Facility
Modifier
Global
Typical Low
$70.79
Median
$70.79
Typical High
$128.82