L0623
Prosthetics & Orthotics
53 States
Sacroiliac orthosis, 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
Short Desc
Sio rig pnl pelv/sac pre ots
Coverage determined by local carrier discretion.
Added Date
2006-01-01
Effective From
2014-01-01
Fee Schedule Rates
Effective Jan 2026Official Medicare DMEPOS pricing for 2026.
| State | Modifier | Non-Rural | Rural |
|---|---|---|---|
|
AK
|
Base Rate |
$202.05
|
Same |
|
AL
|
Base Rate |
$137.13
|
$177.91
|
|
AR
|
Base Rate |
$137.13
|
$177.90
|
|
AZ
|
Base Rate |
$129.31
|
$174.69
|
|
CA
|
Base Rate |
$60.40
|
$174.69
|
|
CO
|
Base Rate |
$90.01
|
$178.51
|
|
CT
|
Base Rate |
$137.13
|
$174.69
|
|
DC
|
Base Rate |
$120.32
|
$174.69
|
|
DE
|
Base Rate |
$120.32
|
$174.69
|
|
FL
|
Base Rate |
$137.13
|
$177.91
|
|
GA
|
Base Rate |
$137.13
|
$177.91
|
|
HI
|
Base Rate |
$202.05
|
Same |
|
IA
|
Base Rate |
$134.44
|
$176.77
|
|
ID
|
Base Rate |
$90.01
|
$174.69
|
|
IL
|
Base Rate |
$116.41
|
$177.31
|
|
IN
|
Base Rate |
$116.41
|
$177.31
|
|
KS
|
Base Rate |
$134.44
|
$176.77
|
|
KY
|
Base Rate |
$137.13
|
$177.91
|
|
LA
|
Base Rate |
$137.13
|
$177.90
|
|
MA
|
Base Rate |
$137.13
|
$174.69
|
|
MD
|
Base Rate |
$120.32
|
$174.69
|
|
ME
|
Base Rate |
$137.13
|
$174.69
|
|
MI
|
Base Rate |
$116.41
|
$177.31
|
|
MN
|
Base Rate |
$134.44
|
$177.31
|
|
MO
|
Base Rate |
$134.44
|
$176.77
|
|
MS
|
Base Rate |
$137.13
|
$177.91
|
|
MT
|
Base Rate |
$90.01
|
$178.51
|
|
NC
|
Base Rate |
$137.13
|
$177.91
|
|
ND
|
Base Rate |
$134.44
|
$178.51
|
|
NE
|
Base Rate |
$134.44
|
$176.77
|
|
NH
|
Base Rate |
$137.13
|
$174.69
|
|
NJ
|
Base Rate |
$120.32
|
$174.69
|
|
NM
|
Base Rate |
$129.31
|
$177.90
|
|
NV
|
Base Rate |
$60.40
|
$174.69
|
|
NY
|
Base Rate |
$120.32
|
$174.69
|
|
OH
|
Base Rate |
$116.41
|
$177.31
|
|
OK
|
Base Rate |
$129.31
|
$177.90
|
|
OR
|
Base Rate |
$60.40
|
$174.69
|
|
PA
|
Base Rate |
$120.32
|
$174.69
|
|
PR
|
Base Rate |
$212.69
|
Same |
|
RI
|
Base Rate |
$137.13
|
$174.69
|
|
SC
|
Base Rate |
$137.13
|
$177.91
|
|
SD
|
Base Rate |
$134.44
|
$178.51
|
|
TN
|
Base Rate |
$137.13
|
$177.91
|
|
TX
|
Base Rate |
$129.31
|
$177.90
|
|
UT
|
Base Rate |
$90.01
|
$178.51
|
|
VA
|
Base Rate |
$137.13
|
$174.69
|
|
VI
|
Base Rate |
$212.69
|
Same |
|
VT
|
Base Rate |
$137.13
|
$174.69
|
|
WA
|
Base Rate |
$60.40
|
$174.69
|
|
WI
|
Base Rate |
$116.41
|
$177.31
|
|
WV
|
Base Rate |
$137.13
|
$174.69
|
|
WY
|
Base Rate |
$90.01
|
$178.51
|