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New Jersey 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
$186.21 / $186.21 / $186.21
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$213.80 / $295.12 / $467.74
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.13 / $331.13 / $562.34
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.88 / $239.88 / $331.13
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$363.08 / $588.84 / $812.83
Horizon BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$549.54 / $549.54 / $549.54
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$199.53 / $363.08 / $616.60
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$245.47 / $281.84 / $457.09