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Montana rates for HCPCS L4050

Replace Molded Calf Lacer, For Custom Fabricated Orthotic Only

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$244.35 / $1,789.24 / $1,789.24
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$290.63 / $488.36 / $488.36
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$290.63 / $397.14 / $488.36
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$259.31 / $465.10 / $488.36
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$290.63 / $366.53 / $533.37
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$209.72 / $232.04 / $265.61