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Montana 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
$278.33 / $349.99 / $2,038.00
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$517.35 / $517.35 / $517.35
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.03 / $556.25 / $556.25
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$331.03 / $452.36 / $556.25
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$295.37 / $529.76 / $556.25
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$331.03 / $417.49 / $556.66
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$238.88 / $264.29 / $404.45