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

New York 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 $120 · 10th–90th $72$2290%20%10th90th$120Professionalmedian $72 · 10th–90th $40$2040%10%20%10th90th$72$0.2$2.0$20.0$200.0$2.0K$20.0K

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
$162.18
Aetna
Setting
Professional
Modifier
Global
Typical Low
$60.26
Median
$72.44
Typical High
$120.23
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$120.23
Median
$120.23
Typical High
$239.88
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$39.81
Median
$39.81
Typical High
$234.42
CDPHP
Setting
Facility
Modifier
Global
Typical Low
$141.25
Median
$151.36
Typical High
$151.36
CDPHP
Setting
Professional
Modifier
Global
Typical Low
$151.36
Median
$151.36
Typical High
$151.36
Cigna
Setting
Facility
Modifier
Global
Typical Low
$52.48
Median
$52.48
Typical High
$186.21
Cigna
Setting
Professional
Modifier
Global
Typical Low
$38.02
Median
$38.02
Typical High
$52.48
Emblem Health
Setting
Facility
Modifier
Global
Typical Low
$120.23
Median
$199.53
Typical High
$457.09
Emblem Health
Setting
Professional
Modifier
Global
Typical Low
$77.62
Median
$144.54
Typical High
$229.09
Excellus BCBS
Setting
Facility
Modifier
Global
Typical Low
$213.80
Median
$213.80
Typical High
$223.87
Excellus BCBS
Setting
Professional
Modifier
Global
Typical Low
$91.20
Median
$97.72
Typical High
$213.80
MVP Health Care
Setting
Facility
Modifier
Global
Typical Low
$457.09
Median
$50,118.72
Typical High
$75,857.76
MVP Health Care
Setting
Professional
Modifier
Global
Typical Low
$93.33
Median
$114.82
Typical High
$208.93
United
Setting
Facility
Modifier
Global
Typical Low
$77.62
Median
$117.49
Typical High
$275.42
United
Setting
Professional
Modifier
Global
Typical Low
$70.79
Median
$117.49
Typical High
$208.93
Univera
Setting
Facility
Modifier
Global
Typical Low
$77.62
Median
$85.11
Typical High
$223.87
Univera
Setting
Professional
Modifier
Global
Typical Low
$77.62
Median
$97.72
Typical High
$213.80