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

California 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 $178 · 10th–90th $138$7940%20%10th90th$178Professionalmedian $182 · 10th–90th $141$1,4450%20%40%10th90th$182$0.2$1.0$5.0$20.0$100.0$500.0$2.0K

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
$181.97
Median
$181.97
Typical High
$1,445.44
Aetna
Setting
Professional
Modifier
Global
Typical Low
$141.25
Median
$181.97
Typical High
$1,445.44
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$138.04
Median
$177.83
Typical High
$758.58
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$181.97
Median
$186.21
Typical High
$436.52
Blue Shield
Setting
Facility
Modifier
Global
Typical Low
$169.82
Median
$524.81
Typical High
$812.83
Blue Shield
Setting
Professional
Modifier
Global
Typical Low
$100.00
Median
$316.23
Typical High
$870.96
Cigna
Setting
Facility
Modifier
Global
Typical Low
$165.96
Median
$229.09
Typical High
$263.03
Cigna
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$165.96
Typical High
$229.09
Contra Costa Health
Setting
Professional
Modifier
Global
Typical Low
$177.83
Median
$213.80
Typical High
$407.38
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$302.00
Typical High
$549.54
Lucent Health
Setting
Facility
Modifier
Global
Typical Low
$1,621.81
Median
$1,621.81
Typical High
$1,621.81
Lucent Health
Setting
Professional
Modifier
Global
Typical Low
$2,511.89
Median
$2,511.89
Typical High
$4,365.16
Molina
Setting
Professional
Modifier
Global
Typical Low
$338.84
Median
$338.84
Typical High
$338.84
Optum
Setting
Professional
Modifier
Global
Typical Low
$54.95
Median
$54.95
Typical High
$70.79
Providence
Setting
Facility
Modifier
Global
Typical Low
$112.20
Median
$302.00
Typical High
$426.58
Providence
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$165.96
Typical High
$323.59
Sutter Health Plus
Setting
Professional
Modifier
Global
Typical Low
$630.96
Median
$630.96
Typical High
$630.96
The Alliance
Setting
Professional
Modifier
Global
Typical Low
$177.83
Median
$229.09
Typical High
$302.00
United
Setting
Facility
Modifier
Global
Typical Low
$25.12
Median
$151.36
Typical High
$416.87
United
Setting
Professional
Modifier
Global
Typical Low
$141.25
Median
$169.82
Typical High
$354.81