go back

Maine rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$175.45 / $243.74 / $243.74
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$357.15 / $462.72 / $857.73
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$183.43 / $192.20 / $192.20
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.19 / $188.19 / $295.14
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.38 / $144.88 / $188.19
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$325.13 / $325.13 / $325.13
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$226.10 / $243.74 / $243.74
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$133.56 / $200.33 / $460.71