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Montana rates for HCPCS L7403

Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$223.87 / $295.12 / $389.05
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$436.52 / $436.52 / $436.52
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$288.40 / $467.74 / $467.74
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$208.93 / $380.19 / $467.74
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$346.74 / $436.52 / $851.14
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$346.74 / $436.52 / $851.14
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$223.87 / $416.87 / $630.96
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $354.81 / $467.74
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$263.03 / $295.12 / $316.23
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$177.83 / $199.53 / $302.00