go back

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

Utah 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 $162 · 10th–90th $162$2240%50%90th$162Professionalmedian $178 · 10th–90th $68$5010%10%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
Facility
Modifier
Global
Typical Low
$162.18
Median
$162.18
Typical High
$162.18
Aetna
Setting
Professional
Modifier
Global
Typical Low
$67.61
Median
$162.18
Typical High
$501.19
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
Molina
Setting
Professional
Modifier
Global
Typical Low
$34.67
Median
$93.33
Typical High
$346.74
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$165.96
Median
$173.78
Typical High
$223.87
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$123.03
Median
$123.03
Typical High
$234.42
Select Health
Setting
Facility
Modifier
Global
Typical Low
$177.83
Median
$177.83
Typical High
$177.83
Select Health
Setting
Professional
Modifier
Global
Typical Low
$89.13
Median
$177.83
Typical High
$338.84
U of Utah Health Plan
Setting
Professional
Modifier
Global
Typical Low
$158.49
Median
$177.83
Typical High
$263.03
United
Setting
Facility
Modifier
Global
Typical Low
$154.88
Median
$186.21
Typical High
$234.42
United
Setting
Professional
Modifier
Global
Typical Low
$44.67
Median
$177.83
Typical High
$263.03