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

Pennsylvania 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 $135 · 10th–90th $62$2400%20%10th90th$135Professionalmedian $72 · 10th–90th $58$1700%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
$61.66
Median
$61.66
Typical High
$239.88
Aetna
Setting
Professional
Modifier
Global
Typical Low
$60.26
Median
$72.44
Typical High
$169.82
Capital Blue Cross
Setting
Facility
Modifier
Global
Typical Low
$5,011.87
Median
$8,511.38
Typical High
$77,624.71
Capital Blue Cross
Setting
Professional
Modifier
Global
Typical Low
$117.49
Median
$117.49
Typical High
$117.49
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
$53.70
Emblem Health
Setting
Professional
Modifier
Global
Typical Low
$109.65
Median
$158.49
Typical High
$229.09
Geisinger
Setting
Facility
Modifier
Global
Typical Low
$120.23
Median
$120.23
Typical High
$120.23
Geisinger
Setting
Professional
Modifier
Global
Typical Low
$72.44
Median
$85.11
Typical High
$120.23
Highmark BCBS
Setting
Facility
Modifier
Global
Typical Low
$467.74
Median
$467.74
Typical High
$467.74
Highmark BCBS
Setting
Professional
Modifier
Global
Typical Low
$112.20
Median
$112.20
Typical High
$112.20
Martin's Point
Setting
Facility
Modifier
Global
Typical Low
$61.66
Median
$61.66
Typical High
$239.88
Martin's Point
Setting
Professional
Modifier
Global
Typical Low
$61.66
Median
$72.44
Typical High
$169.82
UPMC Health Plan
Setting
Facility
Modifier
Global
Typical Low
$134.90
Median
$134.90
Typical High
$190.55
UPMC Health Plan
Setting
Professional
Modifier
Global
Typical Low
$131.83
Median
$134.90
Typical High
$190.55
United
Setting
Facility
Modifier
Global
Typical Low
$77.62
Median
$213.80
Typical High
$213.80
United
Setting
Professional
Modifier
Global
Typical Low
$70.79
Median
$104.71
Typical High
$181.97