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

Michigan 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 $355 · 10th–90th $158$8910%20%10th90th$355Professionalmedian $224 · 10th–90th $141$2880%20%40%10th90th$224$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
$158.49
Typical High
$158.49
Aetna
Setting
Professional
Modifier
Global
Typical Low
$134.90
Median
$158.49
Typical High
$234.42
BCBS
Setting
Facility
Modifier
Global
Typical Low
$295.12
Median
$676.08
Typical High
$1,288.25
BCBS
Setting
Professional
Modifier
Global
Typical Low
$223.87
Median
$223.87
Typical High
$229.09
CareSource
Setting
Facility
Modifier
Global
Typical Low
$169.82
Median
$169.82
Typical High
$169.82
Cigna
Setting
Facility
Modifier
Global
Typical Low
$275.42
Median
$275.42
Typical High
$275.42
Cigna
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$275.42
Typical High
$416.87
Health Alliance Plan
Setting
Facility
Modifier
Global
Typical Low
$154.88
Median
$758.58
Typical High
$831.76
Health Alliance Plan
Setting
Professional
Modifier
Global
Typical Low
$154.88
Median
$281.84
Typical High
$380.19
Priority Health
Setting
Professional
Modifier
Global
Typical Low
$346.74
Median
$346.74
Typical High
$467.74
United
Setting
Facility
Modifier
Global
Typical Low
$131.83
Median
$229.09
Typical High
$416.87
United
Setting
Professional
Modifier
Global
Typical Low
$134.90
Median
$194.98
Typical High
$323.59