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

New York 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 $251 · 10th–90th $145$5620%10%20%10th90th$251Professionalmedian $186 · 10th–90th $141$4900%20%10th90th$186$0.2$2.0$20.0$200.0$2.0K$20.0K

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
$112.20
Median
$158.49
Typical High
$380.19
Aetna
Setting
Professional
Modifier
Global
Typical Low
$112.20
Median
$162.18
Typical High
$223.87
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$338.84
Median
$338.84
Typical High
$676.08
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$186.21
Median
$186.21
Typical High
$575.44
CDPHP
Setting
Facility
Modifier
Global
Typical Low
$257.04
Median
$275.42
Typical High
$275.42
CDPHP
Setting
Professional
Modifier
Global
Typical Low
$275.42
Median
$275.42
Typical High
$275.42
Cigna
Setting
Facility
Modifier
Global
Typical Low
$229.09
Median
$229.09
Typical High
$954.99
Cigna
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$165.96
Typical High
$245.47
Emblem Health
Setting
Facility
Modifier
Global
Typical Low
$338.84
Median
$562.34
Typical High
$1,288.25
Emblem Health
Setting
Professional
Modifier
Global
Typical Low
$213.80
Median
$354.81
Typical High
$645.65
Excellus BCBS
Setting
Facility
Modifier
Global
Typical Low
$251.19
Median
$251.19
Typical High
$263.03
Excellus BCBS
Setting
Professional
Modifier
Global
Typical Low
$199.53
Median
$213.80
Typical High
$251.19
MVP Health Care
Setting
Facility
Modifier
Global
Typical Low
$537.03
Median
$50,118.72
Typical High
$75,857.76
MVP Health Care
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$323.59
Typical High
$380.19
United
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$177.83
Typical High
$537.03
United
Setting
Professional
Modifier
Global
Typical Low
$128.82
Median
$218.78
Typical High
$562.34
Univera
Setting
Facility
Modifier
Global
Typical Low
$199.53
Median
$223.87
Typical High
$263.03
Univera
Setting
Professional
Modifier
Global
Typical Low
$199.53
Median
$213.80
Typical High
$251.19