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Montana rates for HCPCS L5701

Replacement, socket, above knee (AK)/knee disarticulation, including attachment plate, molded to patient model

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,526.37 / $15,699.50 / $15,699.50
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,439.27 / $4,439.27 / $4,439.27
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,550.04 / $4,773.10 / $4,773.10
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,550.04 / $3,881.54 / $4,773.10
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,275.23 / $4,545.81 / $4,773.10
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,550.04 / $3,582.42 / $5,069.12
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,840.13 / $2,035.96 / $3,137.34