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Oklahoma rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$145.07 / $145.07 / $213.80
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$139.69 / $145.07 / $160.53
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
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$97.00 / $190.19 / $1,580.76
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.17 / $150.25 / $303.44
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.17 / $146.66 / $215.55