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Missouri 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
$275.42 / $275.42 / $316.23
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$234.42 / $295.12 / $645.65
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$537.03 / $537.03 / $1,905.46
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$281.84 / $323.59 / $501.19
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$323.59 / $323.59 / $537.03
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$245.47 / $331.13 / $331.13
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.88 / $239.88 / $331.13
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$281.84 / $426.58 / $2,754.23
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$204.17 / $263.03 / $3,981.07
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$245.47 / $426.58 / $426.58
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$204.17 / $263.03 / $398.11