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Nebraska rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$205.36 / $205.36 / $205.36
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$205.36 / $205.36 / $266.66
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$283.01 / $311.32 / $314.47
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.19 / $354.22 / $354.22
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$188.19 / $354.22 / $546.21
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$161.33 / $352.48 / $1,580.76
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$115.77 / $160.65 / $267.75
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$353.18 / $354.22 / $457.52
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$294.00 / $418.63 / $729.74
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$116.47 / $160.65 / $226.33