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Ankle Orthosis, Gauntlet, Custom Fabricated

Arizona rates for HCPCS L1904

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

Rates data updated July 2026.

How much does Ankle Orthosis, Gauntlet, Custom Fabricated cost?

$302

Typical negotiated rate. In Arizona, July 2026.

Insurers have agreed to pay about $302 for this service. The price depends on where it is billed: about $295 from a physician practice, and about $603 from a hospital or other facility. The two figures are alternatives, not parts of one bill.

These are rates insurers have negotiated with providers, not the amount a patient is billed. What you owe depends on your plan's deductible and coinsurance. Based on rates published by 5 insurance carriers under federal price transparency rules.

Where it's billed changes the price

Billed byTypicalRange
Physician practiceA doctor's office, clinic or independent provider$295$245 to $347
FacilityA hospital or hospital-owned outpatient department$603$282 to $955

How much rates vary

Facilitymedian $603 · 10th to 90th $186 to $1,549Professionalmedian $295 · 10th to 90th $234 to $661
$200$500$1K$2Kfacility $603professional $295

Distribution of negotiated rates across all payers (price axis is log-scale). Each curve is scaled to its own total: facility and professional rates are different services, shown together to compare where they cluster. Need provider-level prices or 24+ months of history? Contact us.

Rates by insurance carrier

Insurance Carrier
Aetna
Setting
Professional
Modifier
Global
Typical Low
$234.42
Median
$295.12
Typical High
$354.81
BCBS
Setting
Facility
Modifier
Global
Typical Low
$194.98
Median
$794.33
Typical High
$1,548.82
BCBS
Setting
Professional
Modifier
Global
Typical Low
$549.54
Median
$741.31
Typical High
$1,479.11
Cigna
Setting
Facility
Modifier
Global
Typical Low
$331.13
Median
$331.13
Typical High
$331.13
Cigna
Setting
Professional
Modifier
Global
Typical Low
$239.88
Median
$239.88
Typical High
$331.13
Medica
Setting
Facility
Modifier
Global
Typical Low
$169.82
Median
$467.74
Typical High
$2,754.23
Medica
Setting
Professional
Modifier
Global
Typical Low
$218.78
Median
$263.03
Typical High
$3,981.07
United
Setting
Facility
Modifier
Global
Typical Low
$204.17
Median
$575.44
Typical High
$724.44
United
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$263.03
Typical High
$398.11

Where Arizona sits

The same service costs 4.1 times more in Hawaii than in Nebraska. Every bar is a state, most expensive first. Touch or drag across it to read any state, then open that state for its carriers and full range.

Arizona· 36th of 51

$302

HI $1,000NE $245

Median negotiated rate in each state, from every insurer that publishes one. States where no insurer publishes a rate for this service are not shown.