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

Hawaii 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 $191 · 10th–90th $151$2630%20%10th90th$191Professionalmedian $339 · 10th–90th $112$3550%50%10th90th$339$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
Professional
Modifier
Global
Typical Low
$112.20
Median
$112.20
Typical High
$173.78
Cigna
Setting
Facility
Modifier
Global
Typical Low
$229.09
Median
$229.09
Typical High
$263.03
Cigna
Setting
Professional
Modifier
Global
Typical Low
$229.09
Median
$309.03
Typical High
$416.87
HMSA
Setting
Professional
Modifier
Global
Typical Low
$338.84
Median
$338.84
Typical High
$354.81
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$338.84
Typical High
$478.63
United
Setting
Facility
Modifier
Global
Typical Low
$151.36
Median
$151.36
Typical High
$190.55
United
Setting
Professional
Modifier
Global
Typical Low
$177.83
Median
$234.42
Typical High
$416.87