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Utah 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
$170.63 / $170.63 / $170.63
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$170.63 / $236.58 / $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 / $331.03 / $352.89
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.77 / $386.74 / $502.76
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$463.88 / $517.35 / $517.35
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$294.60 / $370.83 / $556.25
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$203.07 / $264.29 / $338.41