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Hawaii 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
$186.51 / $186.51 / $186.51
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$771.61 / $771.61 / $771.61
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$331.03 / $331.03 / $1,068.42
HMSA
Facility/Professional
Professional
Modifier
Low / Median / High Price
$971.29 / $1,017.06 / $1,017.06
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$582.77 / $971.29 / $1,359.81
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$440.49 / $771.61 / $1,068.42
University Health Alliance
Facility/Professional
Professional
Modifier
Low / Median / High Price
$424.77 / $782.41 / $924.49