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Sacroiliac Orthosis, Flexible, Off-the-Shelf

Wisconsin 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 $68 · 10th–90th $63$1320%50%10th90th$68Professionalmedian $63 · 10th–90th $37$1070%20%10th90th$63$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
$37.15
Median
$72.44
Typical High
$102.33
Aetna
Setting
Professional
Modifier
Global
Typical Low
$37.15
Median
$46.77
Typical High
$81.28
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$64.57
Median
$64.57
Typical High
$107.15
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$60.26
Median
$60.26
Typical High
$72.44
Cigna
Setting
Facility
Modifier
Global
Typical Low
$67.61
Median
$245.47
Typical High
$380.19
Cigna
Setting
Professional
Modifier
Global
Typical Low
$48.98
Median
$107.15
Typical High
$120.23
DeanCare
Setting
Facility
Modifier
Global
Typical Low
$37.15
Median
$63.10
Typical High
$93.33
DeanCare
Setting
Professional
Modifier
Global
Typical Low
$58.88
Median
$120.23
Typical High
$162.18
Medica
Setting
Facility
Modifier
Global
Typical Low
$37.15
Median
$72.44
Typical High
$323.59
Medica
Setting
Professional
Modifier
Global
Typical Low
$47.86
Median
$61.66
Typical High
$114.82
Molina
Setting
Professional
Modifier
Global
Typical Low
$54.95
Median
$64.57
Typical High
$85.11
Network Health
Setting
Facility
Modifier
Global
Typical Low
$165.96
Median
$165.96
Typical High
$165.96
Network Health
Setting
Professional
Modifier
Global
Typical Low
$60.26
Median
$85.11
Typical High
$158.49
Prevea360
Setting
Facility
Modifier
Global
Typical Low
$37.15
Median
$63.10
Typical High
$93.33
Prevea360
Setting
Professional
Modifier
Global
Typical Low
$33.11
Median
$58.88
Typical High
$63.10
Quartz
Setting
Professional
Modifier
Global
Typical Low
$52.48
Median
$75.86
Typical High
$138.04
Quartz
Setting
Facility
Modifier
Global
Typical Low
$67.61
Median
$131.83
Typical High
$331.13
Quartz
Setting
Professional
Modifier
Global
Typical Low
$48.98
Median
$114.82
Typical High
$537.03
Security Health
Setting
Professional
Modifier
Global
Typical Low
$83.18
Median
$95.50
Typical High
$97.72
United
Setting
Facility
Modifier
Global
Typical Low
$35.48
Median
$57.54
Typical High
$79.43
United
Setting
Professional
Modifier
Global
Typical Low
$35.48
Median
$61.66
Typical High
$97.72