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

Maine 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 $389 · 10th–90th $191$4170%20%10th90th$389Professionalmedian $204 · 10th–90th $151$2880%20%10th90th$204$100.0$200.0$500.0$1.0K

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
$144.54
Median
$181.97
Typical High
$208.93
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$331.13
Median
$398.11
Typical High
$446.68
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$186.21
Median
$186.21
Typical High
$239.88
Cigna
Setting
Facility
Modifier
Global
Typical Low
$229.09
Median
$229.09
Typical High
$245.47
Cigna
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$165.96
Typical High
$229.09
Harvard Pilgrim
Setting
Professional
Modifier
Global
Typical Low
$288.40
Median
$288.40
Typical High
$346.74
Martin's Point
Setting
Professional
Modifier
Global
Typical Low
$144.54
Median
$194.98
Typical High
$208.93
United
Setting
Facility
Modifier
Global
Typical Low
$97.72
Median
$151.36
Typical High
$190.55
United
Setting
Professional
Modifier
Global
Typical Low
$128.82
Median
$288.40
Typical High
$288.40