go back

Tennessee 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
$238.34 / $238.34 / $260.41
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$233.93 / $245.86 / $446.11
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$315.64 / $476.78 / $476.78
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$283.18 / $331.03 / $331.03
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$241.65 / $241.65 / $331.03
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$885.75 / $2,763.54 / $3,355.16
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,991.82 / $4,087.62 / $4,109.03
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$176.20 / $258.77 / $397.73