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Custom Mould For A Made-To-Measure Breast Implant

Utah rates for HCPCS 19396

An impression of the chest is taken and shaped so that a breast implant can be manufactured to match the individual's own contour. It is the preparatory step used when a standard, off-the-shelf implant would not fit the chest wall well, and the finished implant is placed inside the body at a later operation.

Rates data updated July 2026.

Facilitymedian $4,571 · 10th–90th $145$8,9130%5%10%10th90th$4,571Professionalmedian $251 · 10th–90th $135$4900%10%10th90th$251$50.0$200.0$1.0K$5.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$144.54
Median
$4,570.88
Typical High
$8,511.38
Aetna
Setting
Professional
Modifier
Global
Typical Low
$134.90
Median
$251.19
Typical High
$416.87
Cigna
Setting
Professional
Modifier
Global
Typical Low
$173.78
Median
$269.15
Typical High
$478.63
Molina
Setting
Professional
Modifier
Global
Typical Low
$32.36
Median
$33.11
Typical High
$338.84
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$5,495.41
Median
$7,585.78
Typical High
$11,481.54
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$186.21
Median
$275.42
Typical High
$478.63
Select Health
Setting
Facility
Modifier
Global
Typical Low
$575.44
Median
$575.44
Typical High
$575.44
Select Health
Setting
Professional
Modifier
Global
Typical Low
$269.15
Median
$512.86
Typical High
$602.56
U of Utah Health Plan
Setting
Professional
Modifier
Global
Typical Low
$194.98
Median
$363.08
Typical High
$512.86
United
Setting
Facility
Modifier
Global
Typical Low
$1,202.26
Median
$5,128.61
Typical High
$8,317.64
United
Setting
Professional
Modifier
Global
Typical Low
$138.04
Median
$257.04
Typical High
$501.19