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North Carolina 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
$463.88 / $463.88 / $800.24
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$258.49 / $463.88 / $463.88
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$482.64 / $785.83 / $967.77
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$301.95 / $397.32 / $397.32
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$327.71 / $331.03 / $331.03
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$241.65 / $331.03 / $630.38
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$170.63 / $463.88 / $603.04
Medcost
Facility/Professional
Professional
Modifier
Low / Median / High Price
$298.00 / $298.00 / $360.21
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$517.35 / $657.40 / $1,010.90
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$203.07 / $264.29 / $401.00
Wellcare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$885.75 / $3,355.16 / $3,355.16
Wellcare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,087.62 / $4,087.62 / $4,109.03