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

Utah 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 $151 · 10th–90th $98$3470%20%40%10th90th$151Professionalmedian $191 · 10th–90th $98$1,4450%10%10th90th$191$50.0$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
$97.72
Median
$97.72
Typical High
$97.72
Aetna
Setting
Professional
Modifier
Global
Typical Low
$97.72
Median
$151.36
Typical High
$1,445.44
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
$229.09
Molina
Setting
Professional
Modifier
Global
Typical Low
$60.26
Median
$251.19
Typical High
$323.59
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$331.13
Median
$346.74
Typical High
$346.74
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$190.55
Median
$245.47
Typical High
$371.54
Select Health
Setting
Facility
Modifier
Global
Typical Low
$354.81
Median
$354.81
Typical High
$354.81
Select Health
Setting
Professional
Modifier
Global
Typical Low
$173.78
Median
$338.84
Typical High
$354.81
U of Utah Health Plan
Setting
Professional
Modifier
Global
Typical Low
$245.47
Median
$354.81
Typical High
$407.38
United
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$151.36
Typical High
$190.55
United
Setting
Professional
Modifier
Global
Typical Low
$120.23
Median
$151.36
Typical High
$234.42