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Missouri rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$168.58 / $168.58 / $224.58
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$154.80 / $174.71 / $266.66
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$322.02 / $338.12 / $1,486.44
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$157.13 / $183.43 / $260.52
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 / $200.62
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$161.76 / $260.64 / $1,580.76
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$124.48 / $160.65 / $391.41
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$117.64 / $160.65 / $330.90