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Replacement Nonmolded Calf Lacer

Utah rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Rates data updated July 2026.

Facilitymedian $151 · 10th–90th $98$3020%20%40%10th90th$151Professionalmedian $182 · 10th–90th $98$1,7380%10%20%10th90th$182$50.0$100.0$200.0$500.0$1.0K

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
$97.72
Median
$97.72
Typical High
$97.72
Aetna
Setting
Professional
Modifier
Global
Typical Low
$97.72
Median
$138.04
Typical High
$1,737.80
Cigna
Setting
Facility
Modifier
Global
Typical Low
$186.21
Median
$186.21
Typical High
$186.21
Cigna
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$138.04
Typical High
$186.21
Molina
Setting
Professional
Modifier
Global
Typical Low
$60.26
Median
$218.78
Typical High
$288.40
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$288.40
Median
$302.00
Typical High
$302.00
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$213.80
Typical High
$346.74
Select Health
Setting
Facility
Modifier
Global
Typical Low
$309.03
Median
$309.03
Typical High
$309.03
Select Health
Setting
Professional
Modifier
Global
Typical Low
$154.88
Median
$309.03
Typical High
$309.03
U of Utah Health Plan
Setting
Professional
Modifier
Global
Typical Low
$213.80
Median
$309.03
Typical High
$371.54
United
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$186.21
Typical High
$263.03
United
Setting
Professional
Modifier
Global
Typical Low
$117.49
Median
$151.36
Typical High
$229.09