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

Montana 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 $102 · 10th–90th $85$2510%20%10th90th$102Professionalmedian $85 · 10th–90th $40$2510%10%10th90th$85$50.0$100.0$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
Professional
Modifier
Global
Typical Low
$39.81
Median
$74.13
Typical High
$257.04
Cigna
Setting
Facility
Modifier
Global
Typical Low
$52.48
Median
$181.97
Typical High
$181.97
Cigna
Setting
Professional
Modifier
Global
Typical Low
$38.02
Median
$181.97
Typical High
$181.97
MountainHealth Co-op
Setting
Facility
Modifier
Global
Typical Low
$85.11
Median
$102.33
Typical High
$251.19
MountainHealth Co-op
Setting
Professional
Modifier
Global
Typical Low
$85.11
Median
$102.33
Typical High
$251.19
Providence
Setting
Facility
Modifier
Global
Typical Low
$52.48
Median
$89.13
Typical High
$181.97
Providence
Setting
Professional
Modifier
Global
Typical Low
$58.88
Median
$100.00
Typical High
$181.97
United
Setting
Facility
Modifier
Global
Typical Low
$75.86
Median
$93.33
Typical High
$117.49
United
Setting
Professional
Modifier
Global
Typical Low
$93.33
Median
$95.50
Typical High
$158.49