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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
$308.63 / $318.18 / $418.94
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$998.68 / $1,348.86 / $1,596.89
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$397.73 / $397.73 / $638.77
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.03 / $331.03 / $408.58
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$241.65 / $331.03 / $331.03
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.99 / $352.39 / $587.32