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Wyoming rates for HCPCS L4055

Replace nonmolded calf lacer, for custom fabricated orthosis only

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$168.66 / $168.66 / $263.72
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$294.11 / $294.11 / $294.11
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$294.11 / $294.11 / $294.11
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.19 / $188.19 / $354.22
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.38 / $137.38 / $188.19
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$135.80 / $150.25 / $166.81