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

Wisconsin 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 $117 · 10th–90th $107$2140%20%40%10th90th$117Professionalmedian $107 · 10th–90th $71$1860%20%40%10th90th$107$0.2$1.0$5.0$20.0$100.0$500.0

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
$70.79
Median
$70.79
Typical High
$70.79
Aetna
Setting
Professional
Modifier
Global
Typical Low
$70.79
Median
$70.79
Typical High
$120.23
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$117.49
Median
$117.49
Typical High
$190.55
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$107.15
Median
$107.15
Typical High
$128.82
Cigna
Setting
Facility
Modifier
Global
Typical Low
$52.48
Median
$416.87
Typical High
$676.08
Cigna
Setting
Professional
Modifier
Global
Typical Low
$38.02
Median
$190.55
Typical High
$218.78
DeanCare
Setting
Facility
Modifier
Global
Typical Low
$70.79
Median
$112.20
Typical High
$138.04
DeanCare
Setting
Professional
Modifier
Global
Typical Low
$112.20
Median
$128.82
Typical High
$162.18
Medica
Setting
Facility
Modifier
Global
Typical Low
$70.79
Median
$125.89
Typical High
$575.44
Medica
Setting
Professional
Modifier
Global
Typical Low
$95.50
Median
$114.82
Typical High
$257.04
Molina
Setting
Professional
Modifier
Global
Typical Low
$50.12
Median
$64.57
Typical High
$70.79
Network Health
Setting
Professional
Modifier
Global
Typical Low
$107.15
Median
$151.36
Typical High
$281.84
Prevea360
Setting
Facility
Modifier
Global
Typical Low
$70.79
Median
$112.20
Typical High
$138.04
Prevea360
Setting
Professional
Modifier
Global
Typical Low
$58.88
Median
$58.88
Typical High
$112.20
Quartz
Setting
Professional
Modifier
Global
Typical Low
$93.33
Median
$134.90
Typical High
$223.87
Quartz
Setting
Facility
Modifier
Global
Typical Low
$52.48
Median
$234.42
Typical High
$602.56
Quartz
Setting
Professional
Modifier
Global
Typical Low
$38.02
Median
$213.80
Typical High
$891.25
United
Setting
Facility
Modifier
Global
Typical Low
$70.79
Median
$109.65
Typical High
$158.49
United
Setting
Professional
Modifier
Global
Typical Low
$70.79
Median
$107.15
Typical High
$173.78