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

Washington 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 $331 · 10th–90th $224$7410%20%10th90th$331Professionalmedian $275 · 10th–90th $166$6030%10%10th90th$275$5.0$20.0$100.0$500.0$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
$223.87
Median
$223.87
Typical High
$537.03
Aetna
Setting
Professional
Modifier
Global
Typical Low
$181.97
Median
$223.87
Typical High
$1,445.44
Asuris Northwest Health
Setting
Facility
Modifier
Global
Typical Low
$316.23
Median
$323.59
Typical High
$331.13
Asuris Northwest Health
Setting
Professional
Modifier
Global
Typical Low
$288.40
Median
$288.40
Typical High
$371.54
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
Kaiser Permanente
Setting
Facility
Modifier
Global
Typical Low
$208.93
Median
$457.09
Typical High
$954.99
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$389.05
Typical High
$707.95
Molina
Setting
Professional
Modifier
Global
Typical Low
$75.86
Median
$257.04
Typical High
$281.84
Pacific Source
Setting
Facility
Modifier
Global
Typical Low
$263.03
Median
$323.59
Typical High
$338.84
Pacific Source
Setting
Professional
Modifier
Global
Typical Low
$331.13
Median
$331.13
Typical High
$363.08
Premera BCBS
Setting
Facility
Modifier
Global
Typical Low
$288.40
Median
$489.78
Typical High
$660.69
Premera BCBS
Setting
Professional
Modifier
Global
Typical Low
$275.42
Median
$275.42
Typical High
$323.59
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$323.59
Median
$323.59
Typical High
$331.13
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$288.40
Median
$288.40
Typical High
$371.54
United
Setting
Facility
Modifier
Global
Typical Low
$151.36
Median
$501.19
Typical High
$501.19
United
Setting
Professional
Modifier
Global
Typical Low
$141.25
Median
$165.96
Typical High
$288.40
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$186.21
Median
$288.40
Typical High
$794.33