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

Minnesota 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 $380 · 10th–90th $132$1,0720%10%20%10th90th$380Professionalmedian $174 · 10th–90th $107$1740%50%10th$174$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
$107.15
Median
$107.15
Typical High
$107.15
Aetna
Setting
Professional
Modifier
Global
Typical Low
$50.12
Median
$95.50
Typical High
$158.49
BCBS
Setting
Facility
Modifier
Global
Typical Low
$158.49
Median
$173.78
Typical High
$467.74
BCBS
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$173.78
Typical High
$173.78
Cigna
Setting
Facility
Modifier
Global
Typical Low
$295.12
Median
$501.19
Typical High
$1,348.96
Cigna
Setting
Professional
Modifier
Global
Typical Low
$151.36
Median
$173.78
Typical High
$194.98
Health Partners
Setting
Facility
Modifier
Global
Typical Low
$380.19
Median
$549.54
Typical High
$1,071.52
Health Partners
Setting
Professional
Modifier
Global
Typical Low
$151.36
Median
$151.36
Typical High
$208.93
Medica
Setting
Facility
Modifier
Global
Typical Low
$72.44
Median
$131.83
Typical High
$575.44
Medica
Setting
Professional
Modifier
Global
Typical Low
$63.10
Median
$95.50
Typical High
$223.87
United
Setting
Facility
Modifier
Global
Typical Low
$1.58
Median
$93.33
Typical High
$257.04
United
Setting
Professional
Modifier
Global
Typical Low
$63.10
Median
$112.20
Typical High
$218.78