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Oregon rates for HCPCS L1904

Ankle orthosis (AO), ankle gauntlet or similar, with or without joints, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$259.92 / $349.99 / $2,038.00
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
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$370.83 / $1,122.14 / $1,463.56
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$317.79 / $435.37 / $544.25
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$393.91 / $503.27 / $556.25
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$420.53 / $517.35 / $582.74
Pacific Source
Facility/Professional
Professional
Modifier
Low / Median / High Price
$420.53 / $529.76 / $540.36
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$317.79 / $455.00 / $556.25
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$241.65 / $463.88 / $582.74
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$441.37 / $880.98 / $1,858.58
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$455.59 / $582.74 / $582.74
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$251.50 / $264.29 / $504.24