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Utah rates for HCPCS L4055

Replace Non-Molded Calf Lacer For Custom Fabricated Orthosis Only

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$97.00 / $97.00 / $97.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$97.00 / $137.01 / $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 / $188.19 / $200.62
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$136.31 / $219.86 / $285.81
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$263.72 / $294.11 / $294.11
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$167.48 / $210.82 / $316.23
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$115.44 / $150.25 / $192.38