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Connecticut 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
$343.31 / $343.31 / $343.31
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$238.43 / $269.17 / $343.31
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$547.41 / $706.35 / $808.14
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$322.16 / $322.16 / $338.07
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 / $331.03
ConnectiCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$459.13 / $459.13 / $459.13
ConnectiCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$356.12 / $459.13 / $600.40
Health New England
Facility/Professional
Professional
Modifier
Low / Median / High Price
$336.58 / $336.58 / $336.58
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.99 / $346.19 / $587.32