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Montana rates for HCPCS L7404

Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$338.84 / $446.68 / $588.84
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$660.69 / $660.69 / $660.69
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$436.52 / $707.95 / $707.95
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$316.23 / $575.44 / $707.95
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$524.81 / $660.69 / $1,288.25
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$524.81 / $660.69 / $1,288.25
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$338.84 / $630.96 / $954.99
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $537.03 / $707.95
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$398.11 / $446.68 / $478.63
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$269.15 / $302.00 / $457.09