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

Iowa 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 $309 · 10th–90th $186$8130%10%10th90th$309Professionalmedian $209 · 10th–90th $120$4070%10%20%10th90th$209$0.5$2.0$10.0$50.0$200.0$1.0K

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
$158.49
Median
$208.93
Typical High
$309.03
Aetna
Setting
Professional
Modifier
Global
Typical Low
$120.23
Median
$190.55
Typical High
$281.84
Cigna
Setting
Facility
Modifier
Global
Typical Low
$275.42
Median
$275.42
Typical High
$380.19
Cigna
Setting
Professional
Modifier
Global
Typical Low
$275.42
Median
$346.74
Typical High
$389.05
Hally Health
Setting
Professional
Modifier
Global
Typical Low
$223.87
Median
$398.11
Typical High
$426.58
Medica
Setting
Facility
Modifier
Global
Typical Low
$199.53
Median
$436.52
Typical High
$1,148.15
Medica
Setting
Professional
Modifier
Global
Typical Low
$190.55
Median
$275.42
Typical High
$691.83
Midlands
Setting
Professional
Modifier
Global
Typical Low
$371.54
Median
$416.87
Typical High
$912.01
Midlands
Setting
Facility
Modifier
Global
Typical Low
$380.19
Median
$380.19
Typical High
$380.19
Midlands
Setting
Professional
Modifier
Global
Typical Low
$691.83
Median
$691.83
Typical High
$691.83
United
Setting
Facility
Modifier
Global
Typical Low
$154.88
Median
$263.03
Typical High
$660.69
United
Setting
Professional
Modifier
Global
Typical Low
$186.21
Median
$208.93
Typical High
$363.08
Wellmark
Setting
Professional
Modifier
Global
Typical Low
$269.15
Median
$338.84
Typical High
$338.84