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

Iowa 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 $263 · 10th–90th $158$8510%20%10th90th$263Professionalmedian $219 · 10th–90th $138$4270%10%20%10th90th$219$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
$158.49
Median
$234.42
Typical High
$251.19
Aetna
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$213.80
Typical High
$323.59
Cigna
Setting
Facility
Modifier
Global
Typical Low
$229.09
Median
$229.09
Typical High
$380.19
Cigna
Setting
Professional
Modifier
Global
Typical Low
$229.09
Median
$398.11
Typical High
$489.78
Hally Health
Setting
Professional
Modifier
Global
Typical Low
$288.40
Median
$398.11
Typical High
$426.58
Medica
Setting
Facility
Modifier
Global
Typical Low
$234.42
Median
$407.38
Typical High
$1,584.89
Medica
Setting
Professional
Modifier
Global
Typical Low
$151.36
Median
$204.17
Typical High
$562.34
Midlands
Setting
Professional
Modifier
Global
Typical Low
$371.54
Median
$398.11
Typical High
$478.63
Midlands
Setting
Facility
Modifier
Global
Typical Low
$380.19
Median
$380.19
Typical High
$380.19
Midlands
Setting
Professional
Modifier
Global
Typical Low
$346.74
Median
$562.34
Typical High
$562.34
United
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$346.74
Typical High
$660.69
United
Setting
Professional
Modifier
Global
Typical Low
$151.36
Median
$169.82
Typical High
$338.84
Wellmark
Setting
Professional
Modifier
Global
Typical Low
$269.15
Median
$338.84
Typical High
$338.84