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Iowa 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
$331.13 / $331.13 / $389.05
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$223.87 / $302.00 / $467.74
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.13 / $331.13 / $602.56
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$331.13 / $630.96 / $794.33
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$457.09 / $630.96 / $676.08
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$363.08 / $691.83 / $2,754.23
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$257.04 / $338.84 / $891.25
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$588.84 / $602.56 / $812.83
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$602.56 / $602.56 / $602.56
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$602.56 / $891.25 / $891.25
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
$204.17 / $363.08 / $870.96
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$263.03 / $263.03 / $489.78
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$416.87 / $524.81 / $524.81