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Ostomy Pouch, Drainable, High Output, Two-Piece, No Filter

Montana rates for HCPCS A4412

Ostomy pouch, drainable, high output, for use on a barrier with flange (two-piece system), without filter, each

Rates data updated July 2026.

Facilitymedian $4 · 10th–90th $2$50%20%10th90th$4Professionalmedian $3 · 10th–90th $1$170%10%10th90th$3$1.0$2.0$5.0$10.0$20.0$50.0

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
Setting
Professional
Modifier
Global
Typical Low
$1.05
Median
$3.02
Typical High
$16.60
BCBS
Setting
Professional
Modifier
Global
Typical Low
$3.72
Median
$3.72
Typical High
$3.72
Cigna
Setting
Facility
Modifier
Global
Typical Low
$2.29
Median
$3.98
Typical High
$3.98
Cigna
Setting
Professional
Modifier
Global
Typical Low
$1.95
Median
$3.98
Typical High
$3.98
MountainHealth Co-op
Setting
Facility
Modifier
Global
Typical Low
$2.88
Median
$3.72
Typical High
$7.24
MountainHealth Co-op
Setting
Professional
Modifier
Global
Typical Low
$2.88
Median
$3.72
Typical High
$7.24
Providence
Setting
Facility
Modifier
Global
Typical Low
$1.82
Median
$3.02
Typical High
$4.57
Providence
Setting
Professional
Modifier
Global
Typical Low
$2.82
Median
$3.98
Typical High
$79.43
United
Setting
Facility
Modifier
Global
Typical Low
$1.26
Median
$1.45
Typical High
$1.48
United
Setting
Professional
Modifier
Global
Typical Low
$1.45
Median
$1.58
Typical High
$2.14