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

West 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 $174 · 10th–90th $174$4680%50%90th$174Professionalmedian $166 · 10th–90th $135$2240%50%10th90th$166$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. Small sample; interpret with caution. 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
$134.90
Median
$165.96
Typical High
$173.78
CareSource
Setting
Facility
Modifier
Global
Typical Low
$223.87
Median
$223.87
Typical High
$467.74
CareSource
Setting
Professional
Modifier
Global
Typical Low
$239.88
Median
$239.88
Typical High
$407.38
Cigna
Setting
Facility
Modifier
Global
Typical Low
$229.09
Median
$954.99
Typical High
$954.99
Cigna
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$165.96
Typical High
$1,659.59
United
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$151.36
Typical High
$354.81
United
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$186.21
Typical High
$275.42