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Oregon rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$128.58 / $183.28 / $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 / $137.38 / $188.19
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$213.87 / $637.76 / $831.82
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$183.28 / $251.09 / $308.88
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$227.16 / $287.20 / $320.81
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$242.51 / $298.37 / $331.29
Pacific Source
Facility/Professional
Professional
Modifier
Low / Median / High Price
$274.98 / $301.17 / $305.52
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$181.06 / $262.39 / $320.81
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.38 / $267.52 / $336.08
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$254.55 / $508.08 / $1,071.89
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$262.76 / $336.08 / $336.08
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$141.43 / $150.25 / $286.66