Flexible pelvic and sacral support brace, prefabricated

Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.

Model: claude-haiku-5-5
Provider: anthropic
API: message_batches
Reasoning effort: low
Max output tokens: 4096
Prompt version (hash): 444523875572
Generated: October 20, 2026

Original text from hospital filings

HC Sacroiliac Ortho Pelvic-Sacral Sup Prefab Tier1

Payers reporting HCPCS L0621

Payer pricing summary

Low

Average

$117

Median

$101

High

$263

Payer rate distribution

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#
1	UnitedHealthcare fee schedule · outpatient · +23 other terms	418	$74	$90	$65	73%	3–30	$1 – $502
2	Aetna fee schedule · outpatient · +22 other terms	404	$73	$81	$48	60%	—	$33 – $665
3	Humana fee schedule · outpatient · +21 other terms	356	$76	$123	$178	144%	—	$34 – $883
4	Blue Cross Blue Shield fee schedule · outpatient · +22 other terms	266	$77	$108	$97	90%	—	$0 – $554
5	WellCare fee schedule · outpatient · +12 other terms	234	$74	$74	$17	23%	—	$13 – $133
6	Devoted fee schedule · outpatient · +7 other terms	179	$76	$73	$11	15%	—	$48 – $108
7	Molina fee schedule · outpatient · +16 other terms	157	$84	$89	$40	44%	—	$33 – $251
8	Cigna fee schedule · outpatient · +20 other terms	130	$79	$137	$107	78%	—	$34 – $454
9	Cigna Healthspring fee schedule · outpatient · +4 other terms	123	$78	$74	$9	12%	—	$50 – $101
10	Anthem fee schedule · outpatient · +17 other terms	98	$74	$142	$121	85%	—	$13 – $487
11	Kaiser fee schedule · outpatient · +17 other terms	82	$51	$109	$92	85%	—	$34 – $443
12	Caresource fee schedule · outpatient · +10 other terms	48	$77	$51	$20	39%	—	$39 – $100
13	Clover fee schedule · outpatient · +3 other terms	44	$76	$75	$9	12%	—	$65 – $98
14	Superior Healthplan fee schedule · outpatient · +2 other terms	41	$76	$76	$4	6%	—	$70 – $100
15	Ambetter facility · fee schedule · outpatient · +10 other terms	40	$117	$150	$54	36%	—	$66 – $233
16	Optum fee schedule · outpatient · +10 other terms	40	$77	$90	$39	43%	—	$48 – $180
17	Oscar fee schedule · outpatient · +9 other terms	36	$71	$78	$15	20%	—	$57 – $128
18	Medicare fee schedule · outpatient · +3 other terms	27	$48	$64	$21	33%	—	$48 – $103
19	Medica facility · fee schedule · outpatient · +14 other terms	24	$76	$71	$20	28%	—	$25 – $123
20	Bcbs Tx fee schedule · outpatient	23	$70	$77	$12	16%	—	$70 – $100
21	Regence facility · fee schedule · outpatient · +9 other terms	20	$52	$67	$30	45%	—	$28 – $122
22	Amerihealth Caritas fee schedule · outpatient · +7 other terms	19	$92	$91	$10	11%	—	$68 – $112
23	MultiPlan fee schedule · outpatient · +17 other terms	19	$284	$291	$120	41%	—	$70 – $481
24	Tricare fee schedule · outpatient · +7 other terms	16	$77	$82	$9	11%	—	$77 – $100
25	Medical Mutual facility · fee schedule · outpatient · +7 other terms	15	$65	$76	$19	25%	—	$35 – $103

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