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Nationwide rates for HCPCS L1904

Ankle orthosis (AO), ankle gauntlet or similar, with or without joints, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$239.88 / $302.00 / $549.54
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$234.42 / $295.12 / $467.74
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$239.88 / $331.13 / $1,258.93
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$281.84 / $331.13 / $645.65
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.13 / $331.13 / $2,041.74
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.88 / $239.88 / $794.33
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$204.17 / $354.81 / $724.44
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$208.93 / $269.15 / $457.09