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Georgia 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
$251.19 / $251.19 / $645.65
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.88 / $288.40 / $467.74
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$537.03 / $1,288.25 / $1,995.26
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$281.84 / $436.52 / $724.44
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$446.68 / $446.68 / $446.68
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$446.68 / $446.68 / $446.68
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.13 / $331.13 / $954.99
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.88 / $239.88 / $630.96
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$380.19 / $537.03 / $794.33
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$537.03 / $724.44 / $1,148.15
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$165.96 / $263.03 / $363.08
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$177.83 / $263.03 / $512.86