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Montana rates for HCPCS L4631

Ankle Foot Orthosis Walking Boot Type Varus/ Valgus Correction Rocker Bottom Anterior Tibial Shell Soft Interface Custom Arch Support Plastic Or Other Material Includes Straps And Closures Custom Fabricated

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$872.12 / $996.99 / $6,385.91
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,637.23 / $1,637.23 / $1,637.23
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,037.25 / $1,760.35 / $1,760.35
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,037.25 / $1,760.35 / $1,760.35
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,037.25 / $1,676.52 / $1,760.35
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,037.25 / $1,321.22 / $1,761.62
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$747.74 / $828.14 / $1,313.43