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Indiana 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
$269.17 / $269.17 / $543.84
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$258.82 / $279.52 / $294.60
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$429.63 / $486.74 / $543.84
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$265.31 / $322.16 / $440.49
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$407.88 / $598.22 / $794.64
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$462.26 / $598.22 / $734.18
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.03 / $331.03 / $543.84
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$241.65 / $331.03 / $557.87
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$176.20 / $264.29 / $397.73