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

Montana 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 $200 · 10th–90th $166$4790%20%10th90th$200Professionalmedian $178 · 10th–90th $78$5010%10%20%10th90th$178$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. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Professional
Modifier
Global
Typical Low
$77.62
Median
$162.18
Typical High
$501.19
BCBS
Setting
Professional
Modifier
Global
Typical Low
$331.13
Median
$331.13
Typical High
$331.13
Cigna
Setting
Facility
Modifier
Global
Typical Low
$275.42
Median
$363.08
Typical High
$363.08
Cigna
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$363.08
Typical High
$363.08
MountainHealth Co-op
Setting
Facility
Modifier
Global
Typical Low
$165.96
Median
$194.98
Typical High
$478.63
MountainHealth Co-op
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$194.98
Typical High
$478.63
Providence
Setting
Facility
Modifier
Global
Typical Low
$114.82
Median
$275.42
Typical High
$398.11
Providence
Setting
Professional
Modifier
Global
Typical Low
$79.43
Median
$218.78
Typical High
$363.08
United
Setting
Facility
Modifier
Global
Typical Low
$186.21
Median
$199.53
Typical High
$234.42
United
Setting
Professional
Modifier
Global
Typical Low
$173.78
Median
$186.21
Typical High
$295.12