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TLSO, Sagittal-Coronal Control, One-Piece Rigid Shell

Alaska rates for HCPCS L0490

Thoracic-lumbar-sacral orthosis (TLSO), sagittal-coronal control, one-piece rigid plastic shell, with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment

Rates data updated July 2026.

Facilitymedian $151 · 10th–90th $98$3390%20%40%10th90th$151Professionalmedian $195 · 10th–90th $170$4570%20%10th90th$195$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. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Professional
Modifier
Global
Typical Low
$169.82
Median
$181.97
Typical High
$281.84
Cigna
Setting
Facility
Modifier
Global
Typical Low
$229.09
Median
$229.09
Typical High
$229.09
Cigna
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$165.96
Typical High
$363.08
Moda Health
Setting
Facility
Modifier
Global
Typical Low
$97.72
Median
$223.87
Typical High
$338.84
Moda Health
Setting
Professional
Modifier
Global
Typical Low
$323.59
Median
$338.84
Typical High
$1,096.48
Premera BCBS
Setting
Facility
Modifier
Global
Typical Low
$288.40
Median
$323.59
Typical High
$338.84
Premera BCBS
Setting
Professional
Modifier
Global
Typical Low
$269.15
Median
$323.59
Typical High
$338.84
Providence
Setting
Facility
Modifier
Global
Typical Low
$97.72
Median
$97.72
Typical High
$354.81
Providence
Setting
Professional
Modifier
Global
Typical Low
$60.26
Median
$229.09
Typical High
$316.23
United
Setting
Facility
Modifier
Global
Typical Low
$151.36
Median
$173.78
Typical High
$190.55
United
Setting
Professional
Modifier
Global
Typical Low
$151.36
Median
$234.42
Typical High
$831.76