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

Washington 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 $186 · 10th–90th $112$5890%20%10th90th$186Professionalmedian $138 · 10th–90th $95$4470%10%10th90th$138$5.0$20.0$100.0$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
$138.04
Median
$138.04
Typical High
$323.59
Aetna
Setting
Professional
Modifier
Global
Typical Low
$95.50
Median
$138.04
Typical High
$501.19
Asuris Northwest Health
Setting
Facility
Modifier
Global
Typical Low
$112.20
Median
$112.20
Typical High
$223.87
Asuris Northwest Health
Setting
Professional
Modifier
Global
Typical Low
$100.00
Median
$117.49
Typical High
$288.40
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
Kaiser Permanente
Setting
Facility
Modifier
Global
Typical Low
$112.20
Median
$354.81
Typical High
$851.14
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$112.20
Median
$302.00
Typical High
$630.96
Molina
Setting
Professional
Modifier
Global
Typical Low
$251.19
Median
$316.23
Typical High
$346.74
Pacific Source
Setting
Facility
Modifier
Global
Typical Low
$114.82
Median
$114.82
Typical High
$323.59
Premera BCBS
Setting
Facility
Modifier
Global
Typical Low
$128.82
Median
$173.78
Typical High
$288.40
Premera BCBS
Setting
Professional
Modifier
Global
Typical Low
$95.50
Median
$95.50
Typical High
$173.78
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$112.20
Median
$112.20
Typical High
$114.82
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$100.00
Median
$117.49
Typical High
$288.40
United
Setting
Facility
Modifier
Global
Typical Low
$95.50
Median
$501.19
Typical High
$501.19
United
Setting
Professional
Modifier
Global
Typical Low
$112.20
Median
$186.21
Typical High
$309.03
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$83.18
Median
$177.83
Typical High
$288.40