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New Mexico 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
$259.77 / $259.77 / $259.77
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$259.77 / $398.94 / $2,038.00
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$317.39 / $423.19 / $504.24
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 / $331.03 / $331.03
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$423.80 / $529.76 / $794.64
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$170.63 / $170.63 / $398.13
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$241.65 / $331.03 / $620.82
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.99 / $264.29 / $398.13