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Alaska rates for HCPCS L1904

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$466.52 / $778.13 / $778.13
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.03 / $331.03 / $331.03
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$241.65 / $331.03 / $352.89
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$170.63 / $170.63 / $170.63
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$503.27 / $862.94 / $1,362.54
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$170.63 / $170.63 / $331.03
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$241.65 / $331.03 / $620.82
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$439.03 / $868.57 / $1,132.92