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West Virginia 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
$326.27 / $326.27 / $524.71
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$262.20 / $312.27 / $343.31
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$410.51 / $789.45 / $1,105.23
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$370.83 / $442.09 / $635.71
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.03 / $331.03 / $679.08
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$241.65 / $331.03 / $2,846.21
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$221.53 / $315.08 / $525.13