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

Washington, DC 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 $135 · 10th–90th $135$5010%50%90th$135Professionalmedian $135 · 10th–90th $135$2290%50%90th$135$100.0$200.0$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. Small sample; interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$134.90
Median
$134.90
Typical High
$134.90
Aetna
Setting
Professional
Modifier
Global
Typical Low
$134.90
Median
$134.90
Typical High
$162.18
CareFirst
Setting
Professional
Modifier
Global
Typical Low
$288.40
Median
$288.40
Typical High
$288.40
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
$234.42
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$218.78
Median
$288.40
Typical High
$660.69
United
Setting
Facility
Modifier
Global
Typical Low
$501.19
Median
$501.19
Typical High
$501.19
United
Setting
Professional
Modifier
Global
Typical Low
$109.65
Median
$165.96
Typical High
$323.59