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

Washington 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 $69 · 10th–90th $58$2570%20%10th90th$69Professionalmedian $69 · 10th–90th $49$1580%10%20%10th90th$69$2.0$10.0$50.0$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
$69.18
Median
$69.18
Typical High
$165.96
Aetna
Setting
Professional
Modifier
Global
Typical Low
$48.98
Median
$69.18
Typical High
$257.04
Asuris Northwest Health
Setting
Facility
Modifier
Global
Typical Low
$57.54
Median
$57.54
Typical High
$114.82
Asuris Northwest Health
Setting
Professional
Modifier
Global
Typical Low
$51.29
Median
$60.26
Typical High
$147.91
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
Kaiser Permanente
Setting
Facility
Modifier
Global
Typical Low
$57.54
Median
$131.83
Typical High
$407.38
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$57.54
Median
$123.03
Typical High
$213.80
Molina
Setting
Professional
Modifier
Global
Typical Low
$51.29
Median
$58.88
Typical High
$64.57
Pacific Source
Setting
Facility
Modifier
Global
Typical Low
$58.88
Median
$58.88
Typical High
$165.96
Premera BCBS
Setting
Facility
Modifier
Global
Typical Low
$66.07
Median
$89.13
Typical High
$134.90
Premera BCBS
Setting
Professional
Modifier
Global
Typical Low
$48.98
Median
$48.98
Typical High
$89.13
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$57.54
Median
$57.54
Typical High
$58.88
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$51.29
Median
$60.26
Typical High
$147.91
United
Setting
Facility
Modifier
Global
Typical Low
$47.86
Median
$257.04
Typical High
$257.04
United
Setting
Professional
Modifier
Global
Typical Low
$57.54
Median
$95.50
Typical High
$158.49
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$36.31
Median
$51.29
Typical High
$147.91