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

South Carolina 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 $204 · 10th–90th $166$4370%20%10th90th$204Professionalmedian $174 · 10th–90th $145$3020%20%10th90th$174$100.0$200.0$500.0$1.0K

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
$169.82
Median
$169.82
Typical High
$169.82
Aetna
Setting
Professional
Modifier
Global
Typical Low
$144.54
Median
$169.82
Typical High
$302.00
BCBS
Setting
Facility
Modifier
Global
Typical Low
$218.78
Median
$316.23
Typical High
$346.74
BCBS
Setting
Professional
Modifier
Global
Typical Low
$181.97
Median
$323.59
Typical High
$426.58
Cigna
Setting
Facility
Modifier
Global
Typical Low
$229.09
Median
$229.09
Typical High
$257.04
Cigna
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$165.96
Typical High
$398.11
Medcost
Setting
Professional
Modifier
Global
Typical Low
$169.82
Median
$169.82
Typical High
$891.25
Medcost
Setting
Facility
Modifier
Global
Typical Low
$165.96
Median
$257.04
Typical High
$549.54
Medcost
Setting
Professional
Modifier
Global
Typical Low
$97.72
Median
$97.72
Typical High
$97.72
Molina
Setting
Professional
Modifier
Global
Typical Low
$229.09
Median
$229.09
Typical High
$229.09
United
Setting
Facility
Modifier
Global
Typical Low
$117.49
Median
$190.55
Typical High
$416.87
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$169.82
Typical High
$229.09