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

Idaho 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 $214 · 10th–90th $117$3800%20%10th90th$214Professionalmedian $204 · 10th–90th $115$3800%20%10th90th$204$0.5$2.0$10.0$50.0$200.0

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
Professional
Modifier
Global
Typical Low
$114.82
Median
$162.18
Typical High
$234.42
BCBS
Setting
Facility
Modifier
Global
Typical Low
$165.96
Median
$331.13
Typical High
$426.58
BCBS
Setting
Professional
Modifier
Global
Typical Low
$354.81
Median
$380.19
Typical High
$380.19
Cigna
Setting
Facility
Modifier
Global
Typical Low
$275.42
Median
$275.42
Typical High
$295.12
Cigna
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$204.17
Typical High
$275.42
Moda Health
Setting
Facility
Modifier
Global
Typical Low
$83.18
Median
$199.53
Typical High
$354.81
Moda Health
Setting
Professional
Modifier
Global
Typical Low
$107.15
Median
$169.82
Typical High
$208.93
Molina
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$30.20
Typical High
$288.40
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$165.96
Median
$165.96
Typical High
$251.19
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$123.03
Median
$123.03
Typical High
$239.88
Select Health
Setting
Facility
Modifier
Global
Typical Low
$177.83
Median
$177.83
Typical High
$457.09
Select Health
Setting
Professional
Modifier
Global
Typical Low
$177.83
Median
$229.09
Typical High
$338.84
United
Setting
Facility
Modifier
Global
Typical Low
$0.30
Median
$204.17
Typical High
$234.42
United
Setting
Professional
Modifier
Global
Typical Low
$173.78
Median
$186.21
Typical High
$234.42