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South Carolina 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
$262.20 / $262.20 / $262.20
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$251.58 / $262.20 / $463.88
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$307.00 / $387.05 / $561.54
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$235.95 / $331.03 / $365.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$241.65 / $318.58 / $331.03
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$235.74 / $380.00 / $832.00
Medcost
Facility/Professional
Professional
Modifier
Low / Median / High Price
$298.00 / $298.00 / $320.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$357.97 / $357.97 / $357.97
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$176.20 / $258.45 / $356.29