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

Oklahoma 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 $170 · 10th–90th $155$4680%20%10th90th$170Professionalmedian $162 · 10th–90th $126$2290%20%10th90th$162$100.0$200.0$500.0$1.0K$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
$154.88
Median
$162.18
Typical High
$162.18
Aetna
Setting
Professional
Modifier
Global
Typical Low
$154.88
Median
$162.18
Typical High
$181.97
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
$165.96
Typical High
$371.54
Medica
Setting
Facility
Modifier
Global
Typical Low
$154.88
Median
$218.78
Typical High
$1,584.89
Medica
Setting
Professional
Modifier
Global
Typical Low
$102.33
Median
$162.18
Typical High
$416.87
United
Setting
Facility
Modifier
Global
Typical Low
$147.91
Median
$281.84
Typical High
$354.81
United
Setting
Professional
Modifier
Global
Typical Low
$102.33
Median
$151.36
Typical High
$218.78