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Arizona 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
$262.20 / $296.67 / $463.88
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$185.44 / $669.90 / $1,211.16
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$463.61 / $618.14 / $842.22
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 / $241.65 / $630.38
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$170.63 / $471.98 / $2,763.54
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$238.64 / $264.29 / $398.13
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$238.88 / $264.29 / $398.13