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

Idaho 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 $324 · 10th–90th $174$4170%20%40%10th90th$324Professionalmedian $240 · 10th–90th $135$3720%20%10th90th$240$0.2$1.0$5.0$20.0$100.0$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. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Professional
Modifier
Global
Typical Low
$131.83
Median
$199.53
Typical High
$288.40
BCBS
Setting
Facility
Modifier
Global
Typical Low
$263.03
Median
$323.59
Typical High
$549.54
BCBS
Setting
Professional
Modifier
Global
Typical Low
$354.81
Median
$371.54
Typical High
$371.54
Cigna
Setting
Facility
Modifier
Global
Typical Low
$208.93
Median
$229.09
Typical High
$239.88
Cigna
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$165.96
Typical High
$229.09
Moda Health
Setting
Facility
Modifier
Global
Typical Low
$97.72
Median
$309.03
Typical High
$354.81
Moda Health
Setting
Professional
Modifier
Global
Typical Low
$275.42
Median
$323.59
Typical High
$338.84
Molina
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$30.20
Typical High
$288.40
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$316.23
Median
$323.59
Typical High
$323.59
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$239.88
Median
$239.88
Typical High
$371.54
Select Health
Setting
Facility
Modifier
Global
Typical Low
$338.84
Median
$346.74
Typical High
$512.86
Select Health
Setting
Professional
Modifier
Global
Typical Low
$218.78
Median
$323.59
Typical High
$371.54
United
Setting
Facility
Modifier
Global
Typical Low
$0.24
Median
$173.78
Typical High
$190.55
United
Setting
Professional
Modifier
Global
Typical Low
$141.25
Median
$151.36
Typical High
$218.78