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New Hampshire rates for HCPCS L4050

Replace Molded Calf Lacer, For Custom Fabricated Orthotic Only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$318.97 / $318.97 / $382.76
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$191.41 / $248.05 / $318.97
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$566.48 / $566.48 / $671.51
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$283.29 / $283.29 / $296.80
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$290.63 / $290.63 / $290.63
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$212.16 / $212.16 / $299.35
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$458.66 / $458.66 / $1,415.65
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$444.22 / $444.22 / $444.22
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$188.41 / $282.61 / $335.57
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$424.28 / $466.71 / $593.99