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

Iowa 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 $158 · 10th–90th $78$4270%10%20%10th90th$158Professionalmedian $105 · 10th–90th $62$2090%10%20%10th90th$105$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
$79.43
Median
$107.15
Typical High
$158.49
Aetna
Setting
Professional
Modifier
Global
Typical Low
$60.26
Median
$95.50
Typical High
$144.54
Cigna
Setting
Facility
Modifier
Global
Typical Low
$52.48
Median
$52.48
Typical High
$194.98
Cigna
Setting
Professional
Modifier
Global
Typical Low
$52.48
Median
$173.78
Typical High
$194.98
Hally Health
Setting
Professional
Modifier
Global
Typical Low
$112.20
Median
$213.80
Typical High
$223.87
Medica
Setting
Facility
Modifier
Global
Typical Low
$95.50
Median
$223.87
Typical High
$575.44
Medica
Setting
Professional
Modifier
Global
Typical Low
$102.33
Median
$144.54
Typical High
$316.23
Midlands
Setting
Professional
Modifier
Global
Typical Low
$190.55
Median
$208.93
Typical High
$467.74
Midlands
Setting
Facility
Modifier
Global
Typical Low
$194.98
Median
$194.98
Typical High
$194.98
United
Setting
Facility
Modifier
Global
Typical Low
$77.62
Median
$134.90
Typical High
$338.84
United
Setting
Professional
Modifier
Global
Typical Low
$95.50
Median
$104.71
Typical High
$186.21
Wellmark
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$173.78
Typical High
$173.78