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Montana rates for HCPCS L6628

Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$478.30 / $1,658.94 / $1,658.94
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$748.67 / $748.67 / $748.67
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$444.49 / $804.96 / $804.96
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$444.49 / $654.60 / $804.96
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$320.56 / $766.63 / $804.96
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$444.49 / $604.16 / $805.55
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$259.26 / $286.85 / $454.94