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Sacroiliac Orthosis, Rigid or Semi-Rigid, Off-the-Shelf

California rates for HCPCS L0623

Sacroiliac orthosis (SO), provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, off-the-shelf

Rates data updated July 2026.

Facilitymedian $37 · 10th–90th $30$1700%20%10th90th$37Professionalmedian $74 · 10th–90th $40$2570%20%10th90th$74$0.2$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
$72.44
Median
$72.44
Typical High
$257.04
Aetna
Setting
Professional
Modifier
Global
Typical Low
$57.54
Median
$72.44
Typical High
$257.04
Ambetter
Setting
Professional
Modifier
Global
Typical Low
$120.23
Median
$120.23
Typical High
$120.23
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$29.51
Median
$37.15
Typical High
$141.25
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$38.90
Median
$39.81
Typical High
$194.98
Blue Shield
Setting
Facility
Modifier
Global
Typical Low
$218.78
Median
$407.38
Typical High
$512.86
Blue Shield
Setting
Professional
Modifier
Global
Typical Low
$100.00
Median
$112.20
Typical High
$234.42
Cigna
Setting
Facility
Modifier
Global
Typical Low
$52.48
Median
$52.48
Typical High
$52.48
Cigna
Setting
Professional
Modifier
Global
Typical Low
$38.02
Median
$38.02
Typical High
$52.48
Contra Costa Health
Setting
Professional
Modifier
Global
Typical Low
$47.86
Median
$66.07
Typical High
$81.28
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$42.66
Median
$158.49
Typical High
$281.84
Lucent Health
Setting
Facility
Modifier
Global
Typical Low
$602.56
Median
$602.56
Typical High
$602.56
Lucent Health
Setting
Professional
Modifier
Global
Typical Low
$891.25
Median
$891.25
Typical High
$891.25
Molina
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Providence
Setting
Facility
Modifier
Global
Typical Low
$28.84
Median
$61.66
Typical High
$138.04
Providence
Setting
Professional
Modifier
Global
Typical Low
$38.02
Median
$38.02
Typical High
$79.43
Sutter Health Plus
Setting
Professional
Modifier
Global
Typical Low
$389.05
Median
$389.05
Typical High
$389.05
The Alliance
Setting
Professional
Modifier
Global
Typical Low
$47.86
Median
$47.86
Typical High
$54.95
United
Setting
Facility
Modifier
Global
Typical Low
$15.85
Median
$93.33
Typical High
$213.80
United
Setting
Professional
Modifier
Global
Typical Low
$58.88
Median
$102.33
Typical High
$177.83