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Maryland 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
$258.49 / $262.20 / $463.88
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$339.00 / $339.00 / $431.73
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.03 / $331.03 / $331.03
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$241.65 / $241.65 / $331.03
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$442.09 / $631.55 / $909.45
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$224.00 / $315.08 / $502.23
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$317.39 / $317.39 / $442.09