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Maine 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
$263.03 / $309.03 / $1,096.48
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$691.83 / $831.76 / $954.99
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$323.59 / $323.59 / $407.38
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.13 / $331.13 / $524.81
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.88 / $239.88 / $331.13
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$616.60 / $616.60 / $741.31
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$245.47 / $346.74 / $1,096.48
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$169.82 / $263.03 / $363.08
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$234.42 / $354.81 / $616.60