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

South Dakota 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 $316 · 10th–90th $234$4680%10%10th90th$316Professionalmedian $288 · 10th–90th $214$4900%20%10th90th$288$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. Small sample; interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$251.19
Median
$251.19
Typical High
$251.19
Aetna
Setting
Professional
Modifier
Global
Typical Low
$213.80
Median
$234.42
Typical High
$288.40
Cigna
Setting
Facility
Modifier
Global
Typical Low
$229.09
Median
$229.09
Typical High
$380.19
Cigna
Setting
Professional
Modifier
Global
Typical Low
$398.11
Median
$398.11
Typical High
$489.78
Medica
Setting
Facility
Modifier
Global
Typical Low
$257.04
Median
$338.84
Typical High
$645.65
Medica
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$229.09
Typical High
$4,168.69
Midlands
Setting
Professional
Modifier
Global
Typical Low
$309.03
Median
$371.54
Typical High
$371.54
Midlands
Setting
Facility
Modifier
Global
Typical Low
$380.19
Median
$380.19
Typical High
$380.19
Midlands
Setting
Professional
Modifier
Global
Typical Low
$309.03
Median
$309.03
Typical High
$616.60
Sanford Health Plan
Setting
Professional
Modifier
Global
Typical Low
$288.40
Median
$346.74
Typical High
$457.09
United
Setting
Facility
Modifier
Global
Typical Low
$169.82
Median
$177.83
Typical High
$251.19
United
Setting
Professional
Modifier
Global
Typical Low
$120.23
Median
$234.42
Typical High
$398.11
Wellmark
Setting
Professional
Modifier
Global
Typical Low
$338.84
Median
$338.84
Typical High
$338.84