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

Michigan 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 $417 · 10th–90th $174$1,3800%10%20%10th90th$417Professionalmedian $195 · 10th–90th $158$3390%20%40%10th90th$195$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
$194.98
Median
$194.98
Typical High
$194.98
Aetna
Setting
Professional
Modifier
Global
Typical Low
$158.49
Median
$181.97
Typical High
$194.98
BCBS
Setting
Facility
Modifier
Global
Typical Low
$446.68
Median
$1,023.29
Typical High
$1,949.84
BCBS
Setting
Professional
Modifier
Global
Typical Low
$323.59
Median
$338.84
Typical High
$354.81
CareSource
Setting
Facility
Modifier
Global
Typical Low
$223.87
Median
$223.87
Typical High
$223.87
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
$229.09
Typical High
$380.19
Health Alliance Plan
Setting
Facility
Modifier
Global
Typical Low
$194.98
Median
$645.65
Typical High
$724.44
Health Alliance Plan
Setting
Professional
Modifier
Global
Typical Low
$169.82
Median
$275.42
Typical High
$416.87
Priority Health
Setting
Professional
Modifier
Global
Typical Low
$173.78
Median
$281.84
Typical High
$380.19
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$275.42
Typical High
$416.87
United
Setting
Professional
Modifier
Global
Typical Low
$120.23
Median
$158.49
Typical High
$245.47