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Rhode Island 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
$239.88 / $309.03 / $1,096.48
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,023.29 / $1,412.54 / $1,659.59
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$295.12 / $398.11 / $758.58
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.13 / $407.38 / $407.38
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.88 / $239.88 / $331.13
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$263.03 / $323.59 / $724.44
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$263.03 / $380.19 / $588.84