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

Utah 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 $72 · 10th–90th $72$890%50%90th$72Professionalmedian $72 · 10th–90th $35$2570%20%10th90th$72$50.0$100.0$200.0

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
$72.44
Median
$72.44
Typical High
$72.44
Aetna
Setting
Professional
Modifier
Global
Typical Low
$34.67
Median
$72.44
Typical High
$257.04
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
Molina
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$47.86
Typical High
$61.66
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$85.11
Median
$87.10
Typical High
$114.82
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$63.10
Median
$63.10
Typical High
$123.03
Select Health
Setting
Facility
Modifier
Global
Typical Low
$89.13
Median
$89.13
Typical High
$89.13
Select Health
Setting
Professional
Modifier
Global
Typical Low
$44.67
Median
$89.13
Typical High
$173.78
U of Utah Health Plan
Setting
Professional
Modifier
Global
Typical Low
$75.86
Median
$89.13
Typical High
$107.15
United
Setting
Facility
Modifier
Global
Typical Low
$75.86
Median
$93.33
Typical High
$117.49
United
Setting
Professional
Modifier
Global
Typical Low
$22.91
Median
$93.33
Typical High
$134.90