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Minnesota rates for HCPCS L4055

Replace Non-Molded Calf Lacer For Custom Fabricated Orthosis Only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$209.26 / $209.26 / $209.26
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.28 / $209.26 / $219.12
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$257.99 / $301.17 / $419.37
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$240.94 / $286.11 / $301.17
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.19 / $929.03 / $2,580.29
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$349.13 / $370.07 / $443.39
Health Partners
Facility/Professional
Facility
Modifier
Low / Median / High Price
$551.54 / $891.35 / $2,031.73
Health Partners
Facility/Professional
Professional
Modifier
Low / Median / High Price
$349.13 / $349.13 / $359.20
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$99.91 / $301.17 / $1,580.76
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.17 / $150.25 / $354.22
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.17 / $150.25 / $391.52