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Utah rates for HCPCS 33955

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,380.38 / $3,388.44 / $6,025.60
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$794.33 / $933.25 / $1,778.28
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,122.02 / $1,230.27 / $1,513.56
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.36 / $60.26 / $4,466.84
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,047.13 / $1,905.46 / $2,041.74
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$741.31 / $1,905.46 / $2,630.27
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,122.02 / $1,288.25 / $4,168.69
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,290.87 / $5,128.61 / $13,803.84
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$794.33 / $1,071.52 / $1,737.80