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

Wisconsin 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 $347 · 10th–90th $263$7080%50%10th90th$347Professionalmedian $324 · 10th–90th $170$5750%20%10th90th$324$0.2$1.0$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
$173.78
Median
$173.78
Typical High
$173.78
Aetna
Setting
Professional
Modifier
Global
Typical Low
$173.78
Median
$173.78
Typical High
$309.03
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$346.74
Median
$346.74
Typical High
$575.44
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$316.23
Median
$323.59
Typical High
$389.05
Cigna
Setting
Facility
Modifier
Global
Typical Low
$229.09
Median
$794.33
Typical High
$1,778.28
Cigna
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$501.19
Typical High
$660.69
DeanCare
Setting
Facility
Modifier
Global
Typical Low
$173.78
Median
$281.84
Typical High
$426.58
DeanCare
Setting
Professional
Modifier
Global
Typical Low
$194.98
Median
$331.13
Typical High
$416.87
Medica
Setting
Facility
Modifier
Global
Typical Low
$173.78
Median
$338.84
Typical High
$1,584.89
Medica
Setting
Professional
Modifier
Global
Typical Low
$151.36
Median
$177.83
Typical High
$380.19
Molina
Setting
Professional
Modifier
Global
Typical Low
$54.95
Median
$70.79
Typical High
$1,047.13
Network Health
Setting
Facility
Modifier
Global
Typical Low
$549.54
Median
$549.54
Typical High
$549.54
Network Health
Setting
Professional
Modifier
Global
Typical Low
$245.47
Median
$389.05
Typical High
$676.08
Prevea360
Setting
Facility
Modifier
Global
Typical Low
$173.78
Median
$281.84
Typical High
$426.58
Prevea360
Setting
Professional
Modifier
Global
Typical Low
$194.98
Median
$331.13
Typical High
$338.84
Quartz
Setting
Professional
Modifier
Global
Typical Low
$346.74
Median
$524.81
Typical High
$912.01
Quartz
Setting
Facility
Modifier
Global
Typical Low
$229.09
Median
$707.95
Typical High
$1,621.81
Quartz
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$512.86
Typical High
$4,365.16
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$177.83
Typical High
$346.74
United
Setting
Professional
Modifier
Global
Typical Low
$120.23
Median
$169.82
Typical High
$316.23