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Montana rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$158.22 / $1,158.59 / $1,158.59
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.19 / $316.23 / $316.23
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$188.19 / $257.16 / $316.23
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$167.91 / $301.17 / $316.23
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$188.19 / $237.35 / $316.45
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$135.80 / $150.25 / $172.00