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

Missouri 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 $263 · 10th–90th $158$5010%20%10th90th$263Professionalmedian $214 · 10th–90th $145$4170%20%10th90th$214$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
$181.97
Aetna
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$162.18
Typical High
$501.19
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$263.03
Median
$263.03
Typical High
$933.25
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$251.19
Typical High
$407.38
BCBS
Setting
Professional
Modifier
Global
Typical Low
$158.49
Median
$158.49
Typical High
$263.03
Cigna
Setting
Facility
Modifier
Global
Typical Low
$275.42
Median
$275.42
Typical High
$416.87
Cigna
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$204.17
Typical High
$275.42
Medica
Setting
Facility
Modifier
Global
Typical Low
$158.49
Median
$251.19
Typical High
$1,148.15
Medica
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$208.93
Typical High
$1,737.80
United
Setting
Facility
Modifier
Global
Typical Low
$186.21
Median
$218.78
Typical High
$275.42
United
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$204.17
Typical High
$295.12