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Tennessee rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$135.50 / $135.50 / $148.04
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$132.99 / $142.38 / $253.61
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$179.44 / $271.05 / $271.05
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$160.97 / $188.19 / $188.19
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.38 / $137.38 / $188.19
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$506.66 / $1,580.76 / $1,907.41
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,765.07 / $2,831.45 / $2,831.45
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.17 / $147.11 / $215.55