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New Hampshire rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$223.87 / $223.87 / $269.15
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$131.83 / $194.98 / $269.15
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$407.38 / $436.52 / $501.19
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$181.97 / $181.97 / $181.97
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$186.21 / $186.21 / $295.12
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.04 / $138.04 / $186.21
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$354.81 / $354.81 / $616.60
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$93.33 / $154.88 / $263.03
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$134.90 / $199.53 / $354.81
Well Sense
Facility/Professional
Facility
Modifier
Low / Median / High Price
$363.08 / $363.08 / $575.44