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

Michigan 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 $145 · 10th–90th $71$4570%20%10th90th$145Professionalmedian $79 · 10th–90th $52$1410%20%10th90th$79$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
$79.43
Typical High
$79.43
Aetna
Setting
Professional
Modifier
Global
Typical Low
$60.26
Median
$72.44
Typical High
$109.65
BCBS
Setting
Facility
Modifier
Global
Typical Low
$151.36
Median
$338.84
Typical High
$645.65
BCBS
Setting
Professional
Modifier
Global
Typical Low
$107.15
Median
$112.20
Typical High
$120.23
CareSource
Setting
Facility
Modifier
Global
Typical Low
$87.10
Median
$87.10
Typical High
$87.10
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
$52.48
Typical High
$177.83
Health Alliance Plan
Setting
Facility
Modifier
Global
Typical Low
$23.44
Median
$58.88
Typical High
$79.43
Health Alliance Plan
Setting
Professional
Modifier
Global
Typical Low
$21.88
Median
$72.44
Typical High
$144.54
Priority Health
Setting
Professional
Modifier
Global
Typical Low
$151.36
Median
$177.83
Typical High
$177.83
United
Setting
Facility
Modifier
Global
Typical Low
$70.79
Median
$117.49
Typical High
$213.80
United
Setting
Professional
Modifier
Global
Typical Low
$70.79
Median
$104.71
Typical High
$173.78