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Massachusetts rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$175.45 / $175.45 / $175.45
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$154.80 / $175.45 / $226.10
AllWays Health Partners
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.03 / $941.08 / $1,907.41
AllWays Health Partners
Facility/Professional
Professional
Modifier
Low / Median / High Price
$147.11 / $304.75 / $392.15
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$232.27 / $232.27 / $689.84
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.19 / $232.27 / $281.51
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.38 / $188.19 / $349.13
Fallon Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$83.43 / $4,618.00 / $9,239.00
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$325.13 / $325.13 / $341.39
Health New England
Facility/Professional
Professional
Modifier
Low / Median / High Price
$191.34 / $191.34 / $191.34
Mass General Brigham
Facility/Professional
Facility
Modifier
Low / Median / High Price
$874.59 / $1,907.41 / $1,907.41
Mass General Brigham
Facility/Professional
Professional
Modifier
Low / Median / High Price
$133.56 / $200.33 / $392.15
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$135.80 / $200.33 / $325.13