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

South Dakota 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 $309 · 10th–90th $234$5250%10%10th90th$309Professionalmedian $257 · 10th–90th $191$3720%10%20%10th90th$257$50.0$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. Small sample; interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$309.03
Median
$309.03
Typical High
$309.03
Aetna
Setting
Professional
Modifier
Global
Typical Low
$190.55
Median
$213.80
Typical High
$234.42
Cigna
Setting
Facility
Modifier
Global
Typical Low
$275.42
Median
$275.42
Typical High
$380.19
Cigna
Setting
Professional
Modifier
Global
Typical Low
$295.12
Median
$302.00
Typical High
$371.54
Medica
Setting
Facility
Modifier
Global
Typical Low
$234.42
Median
$354.81
Typical High
$645.65
Medica
Setting
Professional
Modifier
Global
Typical Low
$169.82
Median
$281.84
Typical High
$1,737.80
Midlands
Setting
Professional
Modifier
Global
Typical Low
$371.54
Median
$371.54
Typical High
$380.19
Midlands
Setting
Facility
Modifier
Global
Typical Low
$380.19
Median
$380.19
Typical High
$380.19
Midlands
Setting
Professional
Modifier
Global
Typical Low
$380.19
Median
$380.19
Typical High
$758.58
Sanford Health Plan
Setting
Professional
Modifier
Global
Typical Low
$257.04
Median
$288.40
Typical High
$354.81
United
Setting
Facility
Modifier
Global
Typical Low
$208.93
Median
$218.78
Typical High
$309.03
United
Setting
Professional
Modifier
Global
Typical Low
$44.67
Median
$263.03
Typical High
$338.84
Wellmark
Setting
Professional
Modifier
Global
Typical Low
$338.84
Median
$338.84
Typical High
$338.84