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Nationwide rates for HCPCS L1904

Ankle Orthosis Ankle Gauntlet Or Similiar With Or Without Joints Custom Fabricated (Revised 01/01/2016)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$286.32 / $294.45 / $369.21
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$258.49 / $296.67 / $397.73
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$538.20 / $631.55 / $1,080.71
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$310.23 / $322.16 / $435.76
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.03 / $331.03 / $365.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$241.65 / $331.03 / $352.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$218.97 / $265.69 / $436.05