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Montana rates for HCPCS L4631

Ankle-foot orthosis (AFO), 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
$851.14 / $1,071.52 / $1,621.81
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,621.81 / $1,621.81 / $1,621.81
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,047.13 / $1,778.28 / $1,778.28
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$758.58 / $1,445.44 / $1,778.28
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,288.25 / $1,621.81 / $3,162.28
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,288.25 / $1,621.81 / $3,162.28
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,000.00 / $1,698.24 / $2,238.72
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $1,318.26 / $1,778.28
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$812.83 / $1,047.13 / $1,071.52
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$741.31 / $831.76 / $954.99