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Minnesota 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
$377.87 / $377.87 / $377.87
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$243.25 / $377.87 / $385.43
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$465.87 / $543.84 / $757.28
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$435.07 / $516.65 / $543.84
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.03 / $1,678.04 / $4,660.60
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$630.38 / $668.20 / $800.58
Health Partners
Facility/Professional
Facility
Modifier
Low / Median / High Price
$996.23 / $1,610.00 / $3,669.78
Health Partners
Facility/Professional
Professional
Modifier
Low / Median / High Price
$630.38 / $630.38 / $648.79
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$175.75 / $543.84 / $2,763.54
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$176.20 / $264.29 / $616.95
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$176.20 / $293.42 / $907.63