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

New Hampshire 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 $282 · 10th–90th $240$3310%20%10th90th$282Professionalmedian $229 · 10th–90th $178$2880%50%10th90th$229$100.0$200.0$500.0$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
$239.88
Median
$239.88
Typical High
$288.40
Aetna
Setting
Professional
Modifier
Global
Typical Low
$120.23
Median
$239.88
Typical High
$288.40
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$269.15
Median
$288.40
Typical High
$331.13
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$239.88
Median
$239.88
Typical High
$239.88
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
$204.17
Typical High
$275.42
Harvard Pilgrim
Setting
Professional
Modifier
Global
Typical Low
$229.09
Median
$229.09
Typical High
$426.58
United
Setting
Facility
Modifier
Global
Typical Low
$117.49
Median
$190.55
Typical High
$234.42
United
Setting
Professional
Modifier
Global
Typical Low
$134.90
Median
$229.09
Typical High
$331.13
Well Sense
Setting
Facility
Modifier
Global
Typical Low
$251.19
Median
$251.19
Typical High
$323.59