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

Ohio 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 $123 · 10th–90th $60$2040%20%40%10th90th$123Professionalmedian $129 · 10th–90th $40$3020%10%20%10th90th$129$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
$60.26
Median
$120.23
Typical High
$144.54
Aetna
Setting
Professional
Modifier
Global
Typical Low
$60.26
Median
$72.44
Typical High
$107.15
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$117.49
Median
$123.03
Typical High
$251.19
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$42.66
Median
$204.17
Typical High
$346.74
CareSource
Setting
Facility
Modifier
Global
Typical Low
$66.07
Median
$112.20
Typical High
$158.49
CareSource
Setting
Professional
Modifier
Global
Typical Low
$87.10
Median
$120.23
Typical High
$181.97
Cigna
Setting
Facility
Modifier
Global
Typical Low
$52.48
Median
$52.48
Typical High
$57.54
Cigna
Setting
Professional
Modifier
Global
Typical Low
$38.02
Median
$38.02
Typical High
$56.23
Medical Mutual of Ohio
Setting
Facility
Modifier
Global
Typical Low
$52.48
Median
$52.48
Typical High
$54.95
Medical Mutual of Ohio
Setting
Professional
Modifier
Global
Typical Low
$38.02
Median
$38.02
Typical High
$38.02
Molina
Setting
Professional
Modifier
Global
Typical Low
$38.90
Median
$53.70
Typical High
$77.62
SummaCare
Setting
Professional
Modifier
Global
Typical Low
$177.83
Median
$194.98
Typical High
$354.81
United
Setting
Facility
Modifier
Global
Typical Low
$77.62
Median
$109.65
Typical High
$181.97
United
Setting
Professional
Modifier
Global
Typical Low
$63.10
Median
$104.71
Typical High
$158.49