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Nationwide rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$128.82 / $169.82 / $309.03
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$128.82 / $162.18 / $263.03
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$138.04 / $186.21 / $707.95
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$158.49 / $181.97 / $380.19
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$186.21 / $186.21 / $1,122.02
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.04 / $138.04 / $436.52
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$114.82 / $199.53 / $407.38
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$114.82 / $151.36 / $251.19