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

Virginia 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 $269 · 10th–90th $186$4170%20%40%10th90th$269Professionalmedian $204 · 10th–90th $120$3630%50%10th90th$204$0.5$2.0$10.0$50.0$200.0$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
$114.82
Median
$199.53
Typical High
$199.53
Aetna
Setting
Professional
Modifier
Global
Typical Low
$114.82
Median
$199.53
Typical High
$234.42
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$269.15
Median
$269.15
Typical High
$288.40
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$239.88
Median
$239.88
Typical High
$501.19
CareFirst
Setting
Professional
Modifier
Global
Typical Low
$223.87
Median
$257.04
Typical High
$257.04
Cigna
Setting
Facility
Modifier
Global
Typical Low
$181.97
Median
$275.42
Typical High
$275.42
Cigna
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$204.17
Typical High
$204.17
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$177.83
Median
$275.42
Typical High
$436.52
Medcost
Setting
Facility
Modifier
Global
Typical Low
$114.82
Median
$223.87
Typical High
$398.11
Medcost
Setting
Professional
Modifier
Global
Typical Low
$223.87
Median
$251.19
Typical High
$338.84
Sentara
Setting
Facility
Modifier
Global
Typical Low
$204.17
Median
$316.23
Typical High
$537.03
Sentara
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$316.23
Typical High
$537.03
United
Setting
Facility
Modifier
Global
Typical Low
$131.83
Median
$190.55
Typical High
$416.87
United
Setting
Professional
Modifier
Global
Typical Low
$186.21
Median
$204.17
Typical High
$323.59