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Sacroiliac Orthosis, Flexible, Off-the-Shelf

Ohio 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 $69 · 10th–90th $44$1230%50%10th90th$69Professionalmedian $51 · 10th–90th $34$870%20%10th90th$51$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
$33.88
Median
$70.79
Typical High
$77.62
Aetna
Setting
Professional
Modifier
Global
Typical Low
$33.88
Median
$38.02
Typical High
$63.10
Ambetter
Setting
Professional
Modifier
Global
Typical Low
$69.18
Median
$69.18
Typical High
$69.18
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$64.57
Median
$69.18
Typical High
$138.04
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$50.12
Median
$63.10
Typical High
$102.33
CareSource
Setting
Facility
Modifier
Global
Typical Low
$37.15
Median
$63.10
Typical High
$89.13
CareSource
Setting
Professional
Modifier
Global
Typical Low
$48.98
Median
$67.61
Typical High
$100.00
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
$77.62
Medical Mutual of Ohio
Setting
Facility
Modifier
Global
Typical Low
$67.61
Median
$67.61
Typical High
$74.13
Medical Mutual of Ohio
Setting
Professional
Modifier
Global
Typical Low
$48.98
Median
$48.98
Typical High
$56.23
Molina
Setting
Professional
Modifier
Global
Typical Low
$44.67
Median
$63.10
Typical High
$91.20
SummaCare
Setting
Professional
Modifier
Global
Typical Low
$91.20
Median
$107.15
Typical High
$213.80
United
Setting
Facility
Modifier
Global
Typical Low
$41.69
Median
$58.88
Typical High
$107.15
United
Setting
Professional
Modifier
Global
Typical Low
$34.67
Median
$51.29
Typical High
$77.62