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

Pennsylvania 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 $138$1,6220%20%10th90th$417Professionalmedian $166 · 10th–90th $135$3310%20%10th90th$166$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
$138.04
Median
$138.04
Typical High
$524.81
Aetna
Setting
Professional
Modifier
Global
Typical Low
$128.82
Median
$158.49
Typical High
$234.42
Capital Blue Cross
Setting
Facility
Modifier
Global
Typical Low
$5,011.87
Median
$8,511.38
Typical High
$77,624.71
Capital Blue Cross
Setting
Professional
Modifier
Global
Typical Low
$331.13
Median
$331.13
Typical High
$331.13
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
$229.09
Emblem Health
Setting
Professional
Modifier
Global
Typical Low
$309.03
Median
$446.68
Typical High
$645.65
Geisinger
Setting
Facility
Modifier
Global
Typical Low
$338.84
Median
$338.84
Typical High
$338.84
Geisinger
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$239.88
Typical High
$338.84
Martin's Point
Setting
Facility
Modifier
Global
Typical Low
$138.04
Median
$138.04
Typical High
$524.81
Martin's Point
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$158.49
Typical High
$281.84
Oscar Health
Setting
Facility
Modifier
Global
Typical Low
$173.78
Median
$173.78
Typical High
$173.78
Oscar Health
Setting
Professional
Modifier
Global
Typical Low
$302.00
Median
$302.00
Typical High
$302.00
UPMC Health Plan
Setting
Facility
Modifier
Global
Typical Low
$537.03
Median
$1,202.26
Typical High
$1,949.84
UPMC Health Plan
Setting
Professional
Modifier
Global
Typical Low
$239.88
Median
$316.23
Typical High
$323.59
United
Setting
Facility
Modifier
Global
Typical Low
$141.25
Median
$416.87
Typical High
$416.87
United
Setting
Professional
Modifier
Global
Typical Low
$128.82
Median
$165.96
Typical High
$346.74