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Nebraska 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
$339.63 / $339.63 / $339.63
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$339.63 / $339.63 / $349.99
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$468.07 / $514.88 / $520.09
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.03 / $585.83 / $585.83
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$331.03 / $585.83 / $903.35
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$272.48 / $582.95 / $2,763.54
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$202.76 / $265.69 / $531.00
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$584.12 / $585.83 / $804.80
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$487.10 / $692.34 / $1,206.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$192.63 / $265.69 / $400.21