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

South Dakota 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 $141 · 10th–90th $83$2630%20%10th90th$141Professionalmedian $132 · 10th–90th $95$1910%10%20%10th90th$132$50.0$100.0$200.0$500.0$1.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Small sample; interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$158.49
Median
$158.49
Typical High
$158.49
Aetna
Setting
Professional
Modifier
Global
Typical Low
$95.50
Median
$109.65
Typical High
$120.23
Cigna
Setting
Facility
Modifier
Global
Typical Low
$52.48
Median
$52.48
Typical High
$194.98
Cigna
Setting
Professional
Modifier
Global
Typical Low
$151.36
Median
$151.36
Typical High
$190.55
Medica
Setting
Facility
Modifier
Global
Typical Low
$120.23
Median
$131.83
Typical High
$323.59
Medica
Setting
Professional
Modifier
Global
Typical Low
$89.13
Median
$144.54
Typical High
$891.25
Midlands
Setting
Professional
Modifier
Global
Typical Low
$190.55
Median
$190.55
Typical High
$194.98
Midlands
Setting
Facility
Modifier
Global
Typical Low
$194.98
Median
$194.98
Typical High
$194.98
Midlands
Setting
Professional
Modifier
Global
Typical Low
$194.98
Median
$194.98
Typical High
$194.98
Sanford Health Plan
Setting
Professional
Modifier
Global
Typical Low
$131.83
Median
$147.91
Typical High
$173.78
United
Setting
Facility
Modifier
Global
Typical Low
$109.65
Median
$109.65
Typical High
$158.49
United
Setting
Professional
Modifier
Global
Typical Low
$22.91
Median
$134.90
Typical High
$177.83
Wellmark
Setting
Professional
Modifier
Global
Typical Low
$173.78
Median
$173.78
Typical High
$173.78