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Wisconsin rates for HCPCS L1904

Ankle orthosis (AO), ankle gauntlet or similar, with or without joints, custom fabricated

Facilitymedian $550 · 10th–90th $447$1,0000%50%10th90th$550Professionalmedian $363 · 10th–90th $251$8320%20%10th90th$363$0.5$2.0$10.0$50.0$200.0$1.0K$5.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$275.42 / $275.42 / $275.42
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$239.88 / $295.12 / $426.58
Anthem BCBS
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$549.54 / $549.54 / $912.01
Anthem BCBS
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$467.74 / $512.86 / $616.60
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$331.13 / $1,288.25 / $2,754.23
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$239.88 / $794.33 / $1,047.13
DeanCare
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$275.42 / $446.68 / $691.83
DeanCare
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$489.78 / $707.95 / $870.96
Medica
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$275.42 / $549.54 / $2,754.23
Medica
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$245.47 / $309.03 / $616.60
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$54.95 / $70.79 / $457.09
Network Health
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$870.96 / $870.96 / $870.96
Network Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$389.05 / $630.96 / $1,096.48
Quartz
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$549.54 / $831.76 / $1,659.59
Quartz
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$331.13 / $1,096.48 / $3,388.44
Quartz
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$239.88 / $478.63 / $4,073.80
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$204.17 / $316.23 / $549.54
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$208.93 / $269.15 / $467.74