go back

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

Wisconsin 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 $229 · 10th–90th $224$4170%20%40%10th90th$229Professionalmedian $214 · 10th–90th $138$3720%20%40%10th90th$214$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
$138.04
Median
$138.04
Typical High
$138.04
Aetna
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$138.04
Typical High
$239.88
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$229.09
Median
$229.09
Typical High
$380.19
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$213.80
Median
$213.80
Typical High
$257.04
Cigna
Setting
Facility
Modifier
Global
Typical Low
$275.42
Median
$933.25
Typical High
$1,348.96
Cigna
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$380.19
Typical High
$426.58
DeanCare
Setting
Facility
Modifier
Global
Typical Low
$138.04
Median
$223.87
Typical High
$346.74
DeanCare
Setting
Professional
Modifier
Global
Typical Low
$223.87
Median
$338.84
Typical High
$380.19
Medica
Setting
Facility
Modifier
Global
Typical Low
$138.04
Median
$251.19
Typical High
$1,148.15
Medica
Setting
Professional
Modifier
Global
Typical Low
$186.21
Median
$218.78
Typical High
$478.63
Molina
Setting
Professional
Modifier
Global
Typical Low
$54.95
Median
$70.79
Typical High
$199.53
Network Health
Setting
Professional
Modifier
Global
Typical Low
$213.80
Median
$354.81
Typical High
$562.34
Prevea360
Setting
Facility
Modifier
Global
Typical Low
$138.04
Median
$223.87
Typical High
$346.74
Prevea360
Setting
Professional
Modifier
Global
Typical Low
$114.82
Median
$114.82
Typical High
$223.87
Quartz
Setting
Professional
Modifier
Global
Typical Low
$186.21
Median
$269.15
Typical High
$512.86
Quartz
Setting
Facility
Modifier
Global
Typical Low
$275.42
Median
$467.74
Typical High
$1,174.90
Quartz
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$416.87
Typical High
$1,737.80
United
Setting
Facility
Modifier
Global
Typical Low
$131.83
Median
$208.93
Typical High
$295.12
United
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$208.93
Typical High
$331.13