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New Mexico rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$150.44 / $150.44 / $150.44
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$150.44 / $231.04 / $1,158.59
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 / $188.19 / $188.19
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$245.44 / $306.80 / $460.20
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$97.00 / $97.00 / $230.55
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.38 / $188.19 / $358.04
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$136.43 / $150.25 / $226.33