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

Ohio 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 $347 · 10th–90th $182$5890%20%40%10th90th$347Professionalmedian $182 · 10th–90th $158$3630%50%10th90th$182$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
Facility
Modifier
Global
Typical Low
$181.97
Median
$263.03
Typical High
$323.59
Aetna
Setting
Professional
Modifier
Global
Typical Low
$144.54
Median
$181.97
Typical High
$234.42
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$346.74
Median
$363.08
Typical High
$741.31
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$199.53
Typical High
$446.68
CareSource
Setting
Facility
Modifier
Global
Typical Low
$169.82
Median
$288.40
Typical High
$407.38
CareSource
Setting
Professional
Modifier
Global
Typical Low
$223.87
Median
$309.03
Typical High
$467.74
Cigna
Setting
Facility
Modifier
Global
Typical Low
$229.09
Median
$229.09
Typical High
$251.19
Cigna
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$165.96
Typical High
$245.47
Medical Mutual of Ohio
Setting
Facility
Modifier
Global
Typical Low
$229.09
Median
$229.09
Typical High
$239.88
Medical Mutual of Ohio
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$165.96
Typical High
$223.87
Molina
Setting
Professional
Modifier
Global
Typical Low
$186.21
Median
$295.12
Typical High
$426.58
SummaCare
Setting
Professional
Modifier
Global
Typical Low
$346.74
Median
$389.05
Typical High
$724.44
United
Setting
Facility
Modifier
Global
Typical Low
$120.23
Median
$275.42
Typical High
$354.81
United
Setting
Professional
Modifier
Global
Typical Low
$112.20
Median
$162.18
Typical High
$239.88