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

Texas 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 $102 · 10th–90th $60$6030%10%20%10th90th$102Professionalmedian $79 · 10th–90th $60$1260%20%10th90th$79$0.2$1.0$5.0$20.0$100.0$500.0$2.0K

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
$70.79
Median
$74.13
Typical High
$91.20
Aetna
Setting
Professional
Modifier
Global
Typical Low
$66.07
Median
$74.13
Typical High
$114.82
BCBS
Setting
Facility
Modifier
Global
Typical Low
$3,162.28
Median
$3,548.13
Typical High
$4,786.30
BCBS
Setting
Professional
Modifier
Global
Typical Low
$83.18
Median
$83.18
Typical High
$83.18
Christus
Setting
Facility
Modifier
Global
Typical Low
$79.43
Median
$128.82
Typical High
$128.82
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
Lucent Health
Setting
Facility
Modifier
Global
Typical Low
$602.56
Median
$602.56
Typical High
$602.56
Lucent Health
Setting
Professional
Modifier
Global
Typical Low
$891.25
Median
$891.25
Typical High
$891.25
Moda Health
Setting
Facility
Modifier
Global
Typical Low
$50.12
Median
$114.82
Typical High
$245.47
Moda Health
Setting
Professional
Modifier
Global
Typical Low
$57.54
Median
$109.65
Typical High
$128.82
Molina
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$138.04
Typical High
$141.25
Providence
Setting
Facility
Modifier
Global
Typical Low
$50.12
Median
$102.33
Typical High
$245.47
Providence
Setting
Professional
Modifier
Global
Typical Low
$38.02
Median
$38.02
Typical High
$52.48
United
Setting
Facility
Modifier
Global
Typical Low
$77.62
Median
$102.33
Typical High
$181.97
United
Setting
Professional
Modifier
Global
Typical Low
$79.43
Median
$125.89
Typical High
$158.49
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$38.90
Median
$128.82
Typical High
$177.83