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Massachusetts 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
$309.03 / $309.03 / $309.03
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.88 / $309.03 / $512.86
AllWays Health Partners
Facility/Professional
Facility
Modifier
Low / Median / High Price
$630.96 / $724.44 / $3,388.44
AllWays Health Partners
Facility/Professional
Professional
Modifier
Low / Median / High Price
$263.03 / $501.19 / $724.44
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$407.38 / $407.38 / $1,230.27
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$512.86 / $645.65 / $645.65
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.13 / $407.38 / $489.78
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.88 / $239.88 / $354.81
Fallon Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$83.18 / $4,897.79 / $9,772.37
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$616.60 / $616.60 / $933.25
Health New England
Facility/Professional
Professional
Modifier
Low / Median / High Price
$338.84 / $338.84 / $338.84
Mass General Brigham
Facility/Professional
Facility
Modifier
Low / Median / High Price
$630.96 / $724.44 / $3,388.44
Mass General Brigham
Facility/Professional
Professional
Modifier
Low / Median / High Price
$263.03 / $537.03 / $724.44
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.42 / $346.74 / $724.44
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$251.19 / $380.19 / $616.60