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Michigan 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
$310.58 / $310.58 / $310.58
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$292.10 / $310.58 / $343.31
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$823.14 / $1,640.00 / $2,986.99
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$516.65 / $543.84 / $734.18
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$344.34 / $353.50 / $410.51
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$435.07 / $435.07 / $435.07
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.03 / $331.03 / $331.03
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$331.03 / $331.03 / $630.38
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$310.58 / $393.01 / $393.01
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$310.58 / $393.01 / $611.66
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $30.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$206.94 / $259.99 / $389.25