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TLSO, Flexible, Sacrococcygeal to T-9, Off-the-Shelf

Hawaii rates for HCPCS L0455

Thoracic-lumbar-sacral orthosis (TLSO), flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, off-the-shelf

Rates data updated July 2026.

Facilitymedian $234 · 10th–90th $186$3240%20%10th90th$234Professionalmedian $398 · 10th–90th $141$4170%50%10th90th$398$50.0$100.0$200.0$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. Small sample; interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Professional
Modifier
Global
Typical Low
$141.25
Median
$141.25
Typical High
$144.54
Cigna
Setting
Facility
Modifier
Global
Typical Low
$275.42
Median
$275.42
Typical High
$323.59
Cigna
Setting
Professional
Modifier
Global
Typical Low
$275.42
Median
$363.08
Typical High
$489.78
HMSA
Setting
Professional
Modifier
Global
Typical Low
$398.11
Median
$398.11
Typical High
$416.87
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$275.42
Median
$398.11
Typical High
$549.54
United
Setting
Facility
Modifier
Global
Typical Low
$186.21
Median
$190.55
Typical High
$234.42
United
Setting
Professional
Modifier
Global
Typical Low
$67.61
Median
$309.03
Typical High
$512.86