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Replacement Nonmolded Calf Lacer

Ohio rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Rates data updated July 2026.

Facilitymedian $309 · 10th–90th $162$5250%20%10th90th$309Professionalmedian $162 · 10th–90th $138$3160%20%10th90th$162$0.2$1.0$5.0$20.0$100.0$500.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$162.18
Median
$251.19
Typical High
$288.40
Aetna
Setting
Professional
Modifier
Global
Typical Low
$128.82
Median
$162.18
Typical High
$204.17
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$309.03
Median
$323.59
Typical High
$660.69
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$147.91
Median
$181.97
Typical High
$398.11
CareSource
Setting
Facility
Modifier
Global
Typical Low
$151.36
Median
$257.04
Typical High
$363.08
CareSource
Setting
Professional
Modifier
Global
Typical Low
$194.98
Median
$269.15
Typical High
$407.38
Cigna
Setting
Facility
Modifier
Global
Typical Low
$186.21
Median
$186.21
Typical High
$208.93
Cigna
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$138.04
Typical High
$186.21
Medical Mutual of Ohio
Setting
Facility
Modifier
Global
Typical Low
$186.21
Median
$186.21
Typical High
$199.53
Medical Mutual of Ohio
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$138.04
Typical High
$186.21
Molina
Setting
Professional
Modifier
Global
Typical Low
$131.83
Median
$181.97
Typical High
$263.03
SummaCare
Setting
Professional
Modifier
Global
Typical Low
$309.03
Median
$346.74
Typical High
$630.96
United
Setting
Facility
Modifier
Global
Typical Low
$120.23
Median
$245.47
Typical High
$346.74
United
Setting
Professional
Modifier
Global
Typical Low
$100.00
Median
$151.36
Typical High
$229.09