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Replacement Nonmolded Calf Lacer

Montana rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Rates data updated July 2026.

Facilitymedian $295 · 10th–90th $195$3720%20%40%10th90th$295Professionalmedian $229 · 10th–90th $98$5750%10%20%10th90th$229$100.0$200.0$500.0$1.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Professional
Modifier
Global
Typical Low
$97.72
Median
$158.49
Typical High
$1,737.80
Cigna
Setting
Facility
Modifier
Global
Typical Low
$186.21
Median
$316.23
Typical High
$316.23
Cigna
Setting
Professional
Modifier
Global
Typical Low
$186.21
Median
$316.23
Typical High
$316.23
MountainHealth Co-op
Setting
Facility
Modifier
Global
Typical Low
$229.09
Median
$295.12
Typical High
$575.44
MountainHealth Co-op
Setting
Professional
Modifier
Global
Typical Low
$229.09
Median
$295.12
Typical High
$575.44
Providence
Setting
Facility
Modifier
Global
Typical Low
$162.18
Median
$281.84
Typical High
$407.38
Providence
Setting
Professional
Modifier
Global
Typical Low
$79.43
Median
$239.88
Typical High
$316.23
United
Setting
Facility
Modifier
Global
Typical Low
$147.91
Median
$186.21
Typical High
$194.98
United
Setting
Professional
Modifier
Global
Typical Low
$134.90
Median
$151.36
Typical High
$229.09