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Sacroiliac Orthosis, Flexible, Off-the-Shelf

South Dakota 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 $93 · 10th–90th $63$1580%10%20%10th90th$93Professionalmedian $72 · 10th–90th $56$1070%20%10th90th$72$20.0$50.0$100.0$200.0$500.0

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

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$93.33
Median
$93.33
Typical High
$93.33
Aetna
Setting
Professional
Modifier
Global
Typical Low
$56.23
Median
$63.10
Typical High
$69.18
Avera
Setting
Professional
Modifier
Global
Typical Low
$107.15
Median
$107.15
Typical High
$112.20
Cigna
Setting
Facility
Modifier
Global
Typical Low
$67.61
Median
$67.61
Typical High
$117.49
Cigna
Setting
Professional
Modifier
Global
Typical Low
$85.11
Median
$85.11
Typical High
$107.15
Medica
Setting
Facility
Modifier
Global
Typical Low
$64.57
Median
$100.00
Typical High
$190.55
Medica
Setting
Professional
Modifier
Global
Typical Low
$46.77
Median
$74.13
Typical High
$524.81
Midlands
Setting
Professional
Modifier
Global
Typical Low
$114.82
Median
$114.82
Typical High
$123.03
Midlands
Setting
Facility
Modifier
Global
Typical Low
$117.49
Median
$117.49
Typical High
$117.49
Midlands
Setting
Professional
Modifier
Global
Typical Low
$123.03
Median
$123.03
Typical High
$229.09
Sanford Health Plan
Setting
Professional
Modifier
Global
Typical Low
$72.44
Median
$83.18
Typical High
$107.15
United
Setting
Facility
Modifier
Global
Typical Low
$57.54
Median
$60.26
Typical High
$87.10
United
Setting
Professional
Modifier
Global
Typical Low
$12.88
Median
$75.86
Typical High
$102.33
Wellmark
Setting
Professional
Modifier
Global
Typical Low
$104.71
Median
$104.71
Typical High
$104.71