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New Hampshire 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
$397.73 / $397.73 / $477.28
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$259.92 / $308.63 / $397.73
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$706.35 / $706.35 / $837.31
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$322.16 / $322.16 / $338.07
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
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$571.90 / $571.90 / $1,765.17
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$234.93 / $352.39 / $418.44
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$529.04 / $581.94 / $740.66