go back

Replacement Nonmolded Calf Lacer

Pennsylvania rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Rates data updated July 2026.

Facilitymedian $407 · 10th–90th $123$9770%20%10th90th$407Professionalmedian $148 · 10th–90th $123$3020%20%10th90th$148$0.2$2.0$20.0$200.0$2.0K$20.0K

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
$123.03
Median
$123.03
Typical High
$478.63
Aetna
Setting
Professional
Modifier
Global
Typical Low
$117.49
Median
$144.54
Typical High
$245.47
Capital Blue Cross
Setting
Facility
Modifier
Global
Typical Low
$5,011.87
Median
$8,511.38
Typical High
$77,624.71
Capital Blue Cross
Setting
Professional
Modifier
Global
Typical Low
$302.00
Median
$302.00
Typical High
$302.00
Cigna
Setting
Facility
Modifier
Global
Typical Low
$186.21
Median
$186.21
Typical High
$467.74
Cigna
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$138.04
Typical High
$186.21
Emblem Health
Setting
Professional
Modifier
Global
Typical Low
$281.84
Median
$398.11
Typical High
$588.84
Geisinger
Setting
Facility
Modifier
Global
Typical Low
$309.03
Median
$309.03
Typical High
$309.03
Geisinger
Setting
Professional
Modifier
Global
Typical Low
$186.21
Median
$213.80
Typical High
$309.03
Martin's Point
Setting
Facility
Modifier
Global
Typical Low
$123.03
Median
$123.03
Typical High
$478.63
Martin's Point
Setting
Professional
Modifier
Global
Typical Low
$123.03
Median
$147.91
Typical High
$269.15
Oscar Health
Setting
Facility
Modifier
Global
Typical Low
$158.49
Median
$158.49
Typical High
$158.49
UPMC Health Plan
Setting
Facility
Modifier
Global
Typical Low
$288.40
Median
$724.44
Typical High
$1,174.90
UPMC Health Plan
Setting
Professional
Modifier
Global
Typical Low
$144.54
Median
$288.40
Typical High
$288.40
United
Setting
Facility
Modifier
Global
Typical Low
$138.04
Median
$407.38
Typical High
$407.38
United
Setting
Professional
Modifier
Global
Typical Low
$117.49
Median
$151.36
Typical High
$309.03