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Montana rates for HCPCS E2617

Custom fabricated wheelchair back cushion, any size, including any type mounting hardware

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,415.69 / $2,415.69 / $2,415.69
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$405.00 / $405.00 / $405.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$405.00 / $405.00 / $417.15
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$405.00 / $405.00 / $405.00
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$405.00 / $405.00 / $417.15