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

Missouri 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 $275 · 10th–90th $178$5890%20%10th90th$275Professionalmedian $186 · 10th–90th $151$4070%20%40%10th90th$186$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
$177.83
Median
$177.83
Typical High
$204.17
Aetna
Setting
Professional
Modifier
Global
Typical Low
$151.36
Median
$181.97
Typical High
$1,445.44
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$346.74
Median
$346.74
Typical High
$1,202.26
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$177.83
Median
$186.21
Typical High
$331.13
BCBS
Setting
Professional
Modifier
Global
Typical Low
$208.93
Median
$208.93
Typical High
$346.74
Cigna
Setting
Facility
Modifier
Global
Typical Low
$229.09
Median
$229.09
Typical High
$338.84
Cigna
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$165.96
Typical High
$229.09
Medica
Setting
Facility
Modifier
Global
Typical Low
$169.82
Median
$269.15
Typical High
$1,584.89
Medica
Setting
Professional
Modifier
Global
Typical Low
$117.49
Median
$169.82
Typical High
$4,168.69
United
Setting
Facility
Modifier
Global
Typical Low
$151.36
Median
$275.42
Typical High
$346.74
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$169.82
Typical High
$302.00