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

New Hampshire 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 $138 · 10th–90th $72$1660%20%10th90th$138Professionalmedian $105 · 10th–90th $39$1260%20%10th90th$105$50.0$100.0$200.0$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
$87.10
Aetna
Setting
Professional
Modifier
Global
Typical Low
$61.66
Median
$72.44
Typical High
$125.89
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$138.04
Median
$147.91
Typical High
$165.96
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$38.90
Median
$38.90
Typical High
$39.81
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
Harvard Pilgrim
Setting
Professional
Modifier
Global
Typical Low
$117.49
Median
$117.49
Typical High
$213.80
United
Setting
Facility
Modifier
Global
Typical Low
$63.10
Median
$93.33
Typical High
$117.49
United
Setting
Professional
Modifier
Global
Typical Low
$69.18
Median
$117.49
Typical High
$138.04
Well Sense
Setting
Facility
Modifier
Global
Typical Low
$128.82
Median
$128.82
Typical High
$128.82