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Below-Knee Prosthesis Protective Cover, Custom-Shaped

Montana rates for HCPCS L5704

Custom shaped protective cover, below knee (BK)

Rates data updated July 2026.

Facilitymedian $692 · 10th–90th $468$8710%20%10th90th$692Professionalmedian $589 · 10th–90th $204$1,3490%10%10th90th$589$100.0$200.0$500.0$1.0K$2.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$537.03
Typical High
$3,162.28
BCBS
Setting
Professional
Modifier
Global
Typical Low
$691.83
Median
$691.83
Typical High
$691.83
Cigna
Setting
Facility
Modifier
Global
Typical Low
$398.11
Median
$741.31
Typical High
$741.31
Cigna
Setting
Professional
Modifier
Global
Typical Low
$398.11
Median
$741.31
Typical High
$741.31
MountainHealth Co-op
Setting
Facility
Modifier
Global
Typical Low
$549.54
Median
$691.83
Typical High
$1,348.96
MountainHealth Co-op
Setting
Professional
Modifier
Global
Typical Low
$549.54
Median
$691.83
Typical High
$1,348.96
Providence
Setting
Facility
Modifier
Global
Typical Low
$346.74
Median
$660.69
Typical High
$912.01
Providence
Setting
Professional
Modifier
Global
Typical Low
$79.43
Median
$562.34
Typical High
$741.31
United
Setting
Facility
Modifier
Global
Typical Low
$416.87
Median
$478.63
Typical High
$501.19
United
Setting
Professional
Modifier
Global
Typical Low
$281.84
Median
$316.23
Typical High
$489.78