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Sacroiliac Orthosis, Flexible, Off-the-Shelf

Washington 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 $66 · 10th–90th $32$1660%20%10th90th$66Professionalmedian $43 · 10th–90th $28$1230%10%10th90th$43$1.0$5.0$20.0$100.0$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. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$42.66
Median
$87.10
Typical High
$100.00
Aetna
Setting
Professional
Modifier
Global
Typical Low
$33.11
Median
$42.66
Typical High
$100.00
Asuris Northwest Health
Setting
Facility
Modifier
Global
Typical Low
$31.62
Median
$31.62
Typical High
$63.10
Asuris Northwest Health
Setting
Professional
Modifier
Global
Typical Low
$28.84
Median
$33.88
Typical High
$91.20
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
Kaiser Permanente
Setting
Facility
Modifier
Global
Typical Low
$32.36
Median
$93.33
Typical High
$251.19
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$32.36
Median
$83.18
Typical High
$169.82
Molina
Setting
Professional
Modifier
Global
Typical Low
$75.86
Median
$104.71
Typical High
$114.82
Pacific Source
Setting
Facility
Modifier
Global
Typical Low
$33.11
Median
$48.98
Typical High
$107.15
Pacific Source
Setting
Professional
Modifier
Global
Typical Low
$29.51
Median
$33.11
Typical High
$102.33
Premera BCBS
Setting
Facility
Modifier
Global
Typical Low
$37.15
Median
$51.29
Typical High
$83.18
Premera BCBS
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$53.70
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$31.62
Median
$31.62
Typical High
$33.11
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$28.84
Median
$33.88
Typical High
$91.20
United
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$151.36
Typical High
$151.36
United
Setting
Professional
Modifier
Global
Typical Low
$31.62
Median
$51.29
Typical High
$87.10
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$23.44
Median
$50.12
Typical High
$91.20