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Montana rates for HCPCS L5704

Custom shaped protective cover, below knee (BK)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$608.84 / $2,111.69 / $2,111.69
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$694.07 / $694.07 / $694.07
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$394.91 / $746.27 / $746.27
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$394.91 / $606.87 / $746.27
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$352.34 / $710.73 / $746.27
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$394.91 / $560.11 / $746.81
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$284.95 / $315.29 / $525.49