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New York rates for HCPCS L1904

Ankle Orthosis Ankle Gauntlet Or Similiar With Or Without Joints Custom Fabricated (Revised 01/01/2016)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$186.51 / $238.43 / $441.33
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$186.51 / $282.54 / $345.41
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$547.87 / $558.83 / $1,095.74
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$322.16 / $322.16 / $868.75
CDPHP
Facility/Professional
Facility
Modifier
Low / Median / High Price
$424.50 / $456.45 / $456.45
CDPHP
Facility/Professional
Professional
Modifier
Low / Median / High Price
$456.45 / $456.45 / $456.45
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 / $331.03
Emblem Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$319.00 / $547.87 / $1,232.71
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$282.91 / $410.90 / $986.17
Excellus BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$292.89 / $292.89 / $292.89
Excellus BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$292.89 / $329.39 / $392.88
MVP Health Care
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.03 / $331.03 / $597.00
MVP Health Care
Facility/Professional
Professional
Modifier
Low / Median / High Price
$241.65 / $326.39 / $787.97
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$182.22 / $293.42 / $502.28
Univera
Facility/Professional
Facility
Modifier
Low / Median / High Price
$329.39 / $329.39 / $342.29
Univera
Facility/Professional
Professional
Modifier
Low / Median / High Price
$292.89 / $329.39 / $349.97