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Idaho 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
$278.33 / $385.43 / $463.88
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.03 / $331.03 / $443.05
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$241.65 / $331.03 / $352.89
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$170.63 / $373.18 / $529.76
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$476.78 / $503.27 / $529.76
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $390.95 / $465.62
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$463.88 / $517.35 / $776.03
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$370.83 / $370.83 / $556.25
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$244.37 / $264.29 / $410.53