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Sacroiliac Orthosis, Flexible, Off-the-Shelf

Pennsylvania 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 $129 · 10th–90th $33$5010%20%10th90th$129Professionalmedian $47 · 10th–90th $33$740%20%10th90th$47$0.1$1.0$10.0$100.0$1.0K$10.0K

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
$33.11
Median
$33.11
Typical High
$128.82
Aetna
Setting
Professional
Modifier
Global
Typical Low
$33.11
Median
$42.66
Typical High
$74.13
Ambetter
Setting
Professional
Modifier
Global
Typical Low
$69.18
Median
$69.18
Typical High
$69.18
AmeriHealth
Setting
Professional
Modifier
Global
Typical Low
$48.98
Median
$48.98
Typical High
$61.66
Capital Blue Cross
Setting
Facility
Modifier
Global
Typical Low
$5,011.87
Median
$8,511.38
Typical High
$77,624.71
Capital Blue Cross
Setting
Professional
Modifier
Global
Typical Low
$66.07
Median
$66.07
Typical High
$66.07
Cigna
Setting
Facility
Modifier
Global
Typical Low
$67.61
Median
$67.61
Typical High
$107.15
Cigna
Setting
Professional
Modifier
Global
Typical Low
$48.98
Median
$48.98
Typical High
$67.61
Emblem Health
Setting
Professional
Modifier
Global
Typical Low
$61.66
Median
$87.10
Typical High
$128.82
Geisinger
Setting
Facility
Modifier
Global
Typical Low
$67.61
Median
$67.61
Typical High
$67.61
Geisinger
Setting
Professional
Modifier
Global
Typical Low
$39.81
Median
$46.77
Typical High
$67.61
Highmark BCBS
Setting
Professional
Modifier
Global
Typical Low
$61.66
Median
$61.66
Typical High
$61.66
Independence Blue Cross
Setting
Professional
Modifier
Global
Typical Low
$48.98
Median
$48.98
Typical High
$48.98
Martin's Point
Setting
Facility
Modifier
Global
Typical Low
$33.11
Median
$33.11
Typical High
$128.82
Martin's Point
Setting
Professional
Modifier
Global
Typical Low
$33.11
Median
$44.67
Typical High
$87.10
Oscar Health
Setting
Facility
Modifier
Global
Typical Low
$57.54
Median
$57.54
Typical High
$57.54
Oscar Health
Setting
Professional
Modifier
Global
Typical Low
$38.90
Median
$38.90
Typical High
$100.00
UPMC Health Plan
Setting
Facility
Modifier
Global
Typical Low
$74.13
Median
$371.54
Typical High
$602.56
UPMC Health Plan
Setting
Professional
Modifier
Global
Typical Low
$70.79
Median
$72.44
Typical High
$74.13
United
Setting
Facility
Modifier
Global
Typical Low
$47.86
Median
$128.82
Typical High
$128.82
United
Setting
Professional
Modifier
Global
Typical Low
$36.31
Median
$51.29
Typical High
$93.33