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Indiana rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$149.06 / $149.06 / $301.17
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$143.33 / $154.80 / $161.76
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$237.92 / $269.55 / $301.17
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$146.91 / $183.43 / $250.42
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$225.88 / $331.29 / $451.76
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$255.99 / $331.29 / $406.58
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.19 / $188.19 / $301.17
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.38 / $188.19 / $308.95
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.17 / $150.25 / $219.95