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New Hampshire 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
$226.10 / $226.10 / $271.32
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$123.95 / $175.45 / $226.10
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$401.56 / $401.56 / $476.01
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$183.43 / $183.43 / $192.20
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
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$325.13 / $325.13 / $1,003.51
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$133.56 / $200.33 / $237.87
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$300.75 / $330.83 / $421.05