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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
$278.80 / $278.80 / $371.42
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$278.80 / $288.94 / $441.01
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$532.57 / $559.20 / $2,458.34
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$268.99 / $322.16 / $431.04
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 / $352.89
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$278.80 / $431.07 / $2,763.54
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$218.97 / $265.69 / $647.33
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$203.64 / $265.69 / $407.28