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

Virginia 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 $339 · 10th–90th $166$4570%20%40%10th90th$339Professionalmedian $182 · 10th–90th $138$3240%50%10th90th$182$0.2$2.0$20.0$200.0$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
$134.90
Median
$165.96
Typical High
$165.96
Aetna
Setting
Professional
Modifier
Global
Typical Low
$134.90
Median
$165.96
Typical High
$181.97
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$338.84
Median
$338.84
Typical High
$363.08
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$186.21
Median
$186.21
Typical High
$389.05
CareFirst
Setting
Professional
Modifier
Global
Typical Low
$288.40
Median
$288.40
Typical High
$288.40
Cigna
Setting
Facility
Modifier
Global
Typical Low
$144.54
Median
$229.09
Typical High
$229.09
Cigna
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$165.96
Typical High
$208.93
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$257.04
Median
$338.84
Typical High
$478.63
Medcost
Setting
Professional
Modifier
Global
Typical Low
$169.82
Median
$223.87
Typical High
$331.13
Medcost
Setting
Facility
Modifier
Global
Typical Low
$134.90
Median
$218.78
Typical High
$389.05
Medcost
Setting
Professional
Modifier
Global
Typical Low
$181.97
Median
$204.17
Typical High
$426.58
Sentara
Setting
Facility
Modifier
Global
Typical Low
$190.55
Median
$288.40
Typical High
$1,071.52
Sentara
Setting
Professional
Modifier
Global
Typical Low
$190.55
Median
$288.40
Typical High
$1,071.52
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$151.36
Typical High
$416.87
United
Setting
Professional
Modifier
Global
Typical Low
$151.36
Median
$165.96
Typical High
$263.03