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Replacement Nonmolded Calf Lacer

Washington rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Rates data updated July 2026.

Facilitymedian $309 · 10th–90th $209$7080%20%10th90th$309Professionalmedian $251 · 10th–90th $151$5890%10%20%10th90th$251$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
Setting
Facility
Modifier
Global
Typical Low
$204.17
Median
$204.17
Typical High
$489.78
Aetna
Setting
Professional
Modifier
Global
Typical Low
$169.82
Median
$204.17
Typical High
$1,737.80
Asuris Northwest Health
Setting
Facility
Modifier
Global
Typical Low
$288.40
Median
$295.12
Typical High
$309.03
Asuris Northwest Health
Setting
Professional
Modifier
Global
Typical Low
$263.03
Median
$263.03
Typical High
$346.74
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
Kaiser Permanente
Setting
Facility
Modifier
Global
Typical Low
$208.93
Median
$446.68
Typical High
$870.96
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$208.93
Median
$371.54
Typical High
$691.83
Molina
Setting
Professional
Modifier
Global
Typical Low
$75.86
Median
$208.93
Typical High
$257.04
Pacific Source
Setting
Facility
Modifier
Global
Typical Low
$239.88
Median
$295.12
Typical High
$309.03
Pacific Source
Setting
Professional
Modifier
Global
Typical Low
$302.00
Median
$309.03
Typical High
$380.19
Premera BCBS
Setting
Facility
Modifier
Global
Typical Low
$269.15
Median
$446.68
Typical High
$616.60
Premera BCBS
Setting
Professional
Modifier
Global
Typical Low
$251.19
Median
$251.19
Typical High
$295.12
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$295.12
Median
$295.12
Typical High
$309.03
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$263.03
Median
$263.03
Typical High
$346.74
United
Setting
Facility
Modifier
Global
Typical Low
$147.91
Median
$407.38
Typical High
$489.78
United
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$173.78
Typical High
$295.12
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$181.97
Typical High
$263.03