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Sacroiliac Orthosis, Flexible, Off-the-Shelf

Texas 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 $72 · 10th–90th $39$3310%10%20%10th90th$72Professionalmedian $45 · 10th–90th $36$690%50%10th90th$45$0.1$1.0$10.0$100.0$1.0K

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
$38.90
Median
$39.81
Typical High
$50.12
Aetna
Setting
Professional
Modifier
Global
Typical Low
$36.31
Median
$42.66
Typical High
$64.57
Ambetter
Setting
Professional
Modifier
Global
Typical Low
$70.79
Median
$72.44
Typical High
$72.44
BCBS
Setting
Facility
Modifier
Global
Typical Low
$3,162.28
Median
$3,548.13
Typical High
$4,786.30
BCBS
Setting
Professional
Modifier
Global
Typical Low
$44.67
Median
$44.67
Typical High
$44.67
Baylor Scott & White
Setting
Professional
Modifier
Global
Typical Low
$46.77
Median
$61.66
Typical High
$72.44
Christus
Setting
Facility
Modifier
Global
Typical Low
$72.44
Median
$72.44
Typical High
$79.43
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
Lucent Health
Setting
Facility
Modifier
Global
Typical Low
$331.13
Median
$331.13
Typical High
$331.13
Lucent Health
Setting
Professional
Modifier
Global
Typical Low
$537.03
Median
$537.03
Typical High
$537.03
Moda Health
Setting
Facility
Modifier
Global
Typical Low
$33.88
Median
$72.44
Typical High
$141.25
Moda Health
Setting
Professional
Modifier
Global
Typical Low
$32.36
Median
$43.65
Typical High
$72.44
Molina
Setting
Professional
Modifier
Global
Typical Low
$75.86
Median
$75.86
Typical High
$81.28
Providence
Setting
Facility
Modifier
Global
Typical Low
$33.88
Median
$72.44
Typical High
$141.25
Providence
Setting
Professional
Modifier
Global
Typical Low
$48.98
Median
$48.98
Typical High
$67.61
United
Setting
Facility
Modifier
Global
Typical Low
$39.81
Median
$57.54
Typical High
$107.15
United
Setting
Professional
Modifier
Global
Typical Low
$42.66
Median
$63.10
Typical High
$74.13
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$61.66
Median
$72.44
Typical High
$97.72