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Ohio rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$161.76 / $161.76 / $807.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$145.05 / $161.76 / $189.88
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$282.80 / $331.29 / $858.33
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$146.91 / $176.37 / $391.52
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$225.88 / $301.17 / $406.58
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$195.76 / $301.17 / $644.87
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.19 / $188.19 / $388.44
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.38 / $137.38 / $188.19
Medical Mutual of Ohio
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.19 / $188.19 / $188.19
Medical Mutual of Ohio
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.38 / $188.19 / $188.19
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$127.76 / $175.67 / $230.30
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.17 / $148.91 / $226.11