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Sacroiliac Orthosis, Rigid or Semi-Rigid, Custom Fabricated

Nebraska rates for HCPCS L0624

Sacroiliac orthosis (SO), provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated

Rates data updated July 2026.

How much rates vary

Facilitymedian $62 · 10th to 90th $40 to $89Professionalmedian $40 · 10th to 90th $40 to $40
$50$100facility $62professional $40

Distribution of negotiated rates across all payers (price axis is log-scale). Each curve is scaled to its own total: facility and professional rates are different services, shown together to compare where they cluster. Small sample; interpret with caution. Need provider-level prices or 24+ months of history? Contact us.

Rates by insurance carrier

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$39.81
Median
$39.81
Typical High
$39.81
Aetna
Setting
Professional
Modifier
Global
Typical Low
$39.81
Median
$39.81
Typical High
$39.81
Medica
Setting
Facility
Modifier
Global
Typical Low
$39.81
Median
$67.61
Typical High
$89.13
Medica
Setting
Professional
Modifier
Global
Typical Low
$39.81
Median
$39.81
Typical High
$39.81