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Ankle Orthosis, Gauntlet, Off-the-Shelf

Washington rates for HCPCS L1902

Ankle orthosis (AO), ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf

Rates data updated July 2026.

Facilitymedian $107 · 10th–90th $68$2140%20%10th90th$107Professionalmedian $91 · 10th–90th $45$2040%10%10th90th$91$1.0$5.0$20.0$100.0$500.0

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
$45.71
Median
$74.13
Typical High
$177.83
Aetna
Setting
Professional
Modifier
Global
Typical Low
$41.69
Median
$77.62
Typical High
$218.78
Ambetter
Setting
Professional
Modifier
Global
Typical Low
$54.95
Median
$85.11
Typical High
$151.36
Asuris Northwest Health
Setting
Facility
Modifier
Global
Typical Low
$104.71
Median
$107.15
Typical High
$109.65
Asuris Northwest Health
Setting
Professional
Modifier
Global
Typical Low
$95.50
Median
$95.50
Typical High
$123.03
Cigna
Setting
Facility
Modifier
Global
Typical Low
$57.54
Median
$57.54
Typical High
$57.54
Cigna
Setting
Professional
Modifier
Global
Typical Low
$42.66
Median
$42.66
Typical High
$57.54
Kaiser Permanente
Setting
Facility
Modifier
Global
Typical Low
$61.66
Median
$134.90
Typical High
$316.23
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$61.66
Median
$120.23
Typical High
$208.93
Molina
Setting
Professional
Modifier
Global
Typical Low
$75.86
Median
$107.15
Typical High
$117.49
Pacific Source
Setting
Facility
Modifier
Global
Typical Low
$87.10
Median
$107.15
Typical High
$109.65
Pacific Source
Setting
Professional
Modifier
Global
Typical Low
$89.13
Median
$109.65
Typical High
$120.23
Premera BCBS
Setting
Facility
Modifier
Global
Typical Low
$95.50
Median
$162.18
Typical High
$218.78
Premera BCBS
Setting
Professional
Modifier
Global
Typical Low
$91.20
Median
$91.20
Typical High
$107.15
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$107.15
Median
$107.15
Typical High
$109.65
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$95.50
Median
$95.50
Typical High
$123.03
United
Setting
Facility
Modifier
Global
Typical Low
$44.67
Median
$123.03
Typical High
$147.91
United
Setting
Professional
Modifier
Global
Typical Low
$41.69
Median
$52.48
Typical High
$87.10
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$41.69
Median
$95.50
Typical High
$169.82