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Washington rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Facilitymedian $309 · 10th–90th $204–$7760%20%10th90th$309Professionalmedian $209 · 10th–90th $138–$4790%10%20%10th90th$209$1.0$5.0$20.0$100.0$500.0$2.0K

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
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$204.17 / $204.17 / $489.78
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$138.04 / $181.97 / $269.15
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$263.03 / $295.12 / $295.12
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$263.03 / $263.03 / $346.74
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$186.21 / $186.21 / $186.21
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$138.04 / $138.04 / $186.21
Kaiser Permanente
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$190.55 / $446.68 / $870.96
Kaiser Permanente
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$190.55 / $389.05 / $691.83
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$75.86 / $208.93 / $257.04
Pacific Source
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$239.88 / $295.12 / $309.03
Pacific Source
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$302.00 / $309.03 / $380.19
Premera BCBS
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$269.15 / $446.68 / $616.60
Premera BCBS
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$251.19 / $251.19 / $295.12
Regence BlueShield
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$295.12 / $295.12 / $295.12
Regence BlueShield
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$263.03 / $263.03 / $346.74
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$147.91 / $407.38 / $489.78
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$141.25 / $173.78 / $288.40
Wellpoint
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$165.96 / $218.78 / $467.74