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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
$186.51 / $186.51 / $186.51
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$186.51 / $259.92 / $318.18
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.03 / $331.03 / $547.87
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$241.65 / $241.65 / $479.73
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$500.53 / $504.04 / $717.71
Horizon BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$535.03 / $547.87 / $547.87
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.99 / $273.32 / $547.87