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Arizona rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$149.06 / $160.62 / $263.72
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$105.42 / $380.84 / $688.55
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$263.56 / $351.42 / $478.80
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.19 / $188.19 / $188.19
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.38 / $137.38 / $349.13
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$97.00 / $268.31 / $1,580.76
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$135.66 / $150.25 / $226.33
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$135.80 / $150.25 / $226.33