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

Pennsylvania 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 $295 · 10th–90th $120$4680%20%10th90th$295Professionalmedian $162 · 10th–90th $120$2510%20%10th90th$162$0.5$5.0$50.0$500.0$5.0K$50.0K

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
$120.23
Median
$120.23
Typical High
$467.74
Aetna
Setting
Professional
Modifier
Global
Typical Low
$120.23
Median
$144.54
Typical High
$245.47
Capital Blue Cross
Setting
Facility
Modifier
Global
Typical Low
$5,011.87
Median
$8,511.38
Typical High
$77,624.71
Capital Blue Cross
Setting
Professional
Modifier
Global
Typical Low
$229.09
Median
$229.09
Typical High
$229.09
Cigna
Setting
Facility
Modifier
Global
Typical Low
$275.42
Median
$275.42
Typical High
$446.68
Cigna
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$204.17
Typical High
$275.42
Emblem Health
Setting
Professional
Modifier
Global
Typical Low
$218.78
Median
$309.03
Typical High
$446.68
Geisinger
Setting
Facility
Modifier
Global
Typical Low
$234.42
Median
$234.42
Typical High
$234.42
Geisinger
Setting
Professional
Modifier
Global
Typical Low
$141.25
Median
$165.96
Typical High
$234.42
Martin's Point
Setting
Facility
Modifier
Global
Typical Low
$120.23
Median
$120.23
Typical High
$467.74
Martin's Point
Setting
Professional
Modifier
Global
Typical Low
$120.23
Median
$144.54
Typical High
$251.19
UPMC Health Plan
Setting
Facility
Modifier
Global
Typical Low
$295.12
Median
$295.12
Typical High
$831.76
UPMC Health Plan
Setting
Professional
Modifier
Global
Typical Low
$295.12
Median
$295.12
Typical High
$295.12
United
Setting
Facility
Modifier
Global
Typical Low
$173.78
Median
$416.87
Typical High
$416.87
United
Setting
Professional
Modifier
Global
Typical Low
$134.90
Median
$204.17
Typical High
$354.81