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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
$360.94 / $1,251.91 / $1,251.91
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$438.91 / $438.91 / $438.91
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$286.80 / $471.91 / $471.91
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$286.80 / $471.91 / $471.91
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$221.42 / $449.44 / $471.91
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$349.52 / $362.04 / $472.26
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$179.08 / $198.13 / $305.32