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Oklahoma 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
$250.50 / $250.50 / $369.21
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$241.22 / $250.50 / $318.18
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
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$170.63 / $328.42 / $2,763.54
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$176.20 / $264.29 / $523.96
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$176.20 / $258.77 / $379.17