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Montana rates for HCPCS L5695

Addition to lower extremity, above knee (AK), pelvic control, sleeve suspension, neoprene or equal, each

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$217.09 / $752.99 / $752.99
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$47,000.00 / $81,499.99 / $94,999.99
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$232.39 / $232.39 / $232.39
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$122.31 / $249.87 / $249.87
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$122.31 / $203.19 / $249.87
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$109.13 / $237.97 / $249.87
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$122.31 / $187.53 / $250.04
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$88.26 / $97.65 / $154.88