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Mouthpiece

Pennsylvania rates for HCPCS A4617

Mouthpiece

Rates data updated July 2026.

Facilitymedian $3 · 10th–90th $2$230%20%10th90th$3Professionalmedian $3 · 10th–90th $1$40%20%40%10th90th$3$0.1$0.5$5.0$50.0$500.0$5.0K$50.0K

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
$2.14
Median
$2.14
Typical High
$3.39
Aetna
Setting
Professional
Modifier
Global
Typical Low
$1.32
Median
$2.63
Typical High
$4.37
Ambetter
Setting
Professional
Modifier
Global
Typical Low
$2.19
Median
$4.47
Typical High
$6.17
Capital Blue Cross
Setting
Facility
Modifier
Global
Typical Low
$5,011.87
Median
$8,511.38
Typical High
$77,624.71
Capital Blue Cross
Setting
Professional
Modifier
Global
Typical Low
$4.37
Median
$4.37
Typical High
$4.37
Cigna
Setting
Facility
Modifier
Global
Typical Low
$6.76
Median
$6.76
Typical High
$6.76
Cigna
Setting
Professional
Modifier
Global
Typical Low
$1.82
Median
$1.82
Typical High
$1.82
Emblem Health
Setting
Professional
Modifier
Global
Typical Low
$3.02
Median
$5.75
Typical High
$8.13
Geisinger
Setting
Facility
Modifier
Global
Typical Low
$4.47
Median
$4.47
Typical High
$4.47
Geisinger
Setting
Professional
Modifier
Global
Typical Low
$2.63
Median
$2.63
Typical High
$4.47
Highmark BCBS
Setting
Professional
Modifier
Global
Typical Low
$2.95
Median
$3.24
Typical High
$3.24
Independence Blue Cross
Setting
Professional
Modifier
Global
Typical Low
$3.16
Median
$3.16
Typical High
$3.16
Martin's Point
Setting
Facility
Modifier
Global
Typical Low
$2.14
Median
$2.14
Typical High
$3.39
Martin's Point
Setting
Professional
Modifier
Global
Typical Low
$1.26
Median
$2.63
Typical High
$3.80
Oscar Health
Setting
Professional
Modifier
Global
Typical Low
$5.89
Median
$6.76
Typical High
$8.51
UPMC Health Plan
Setting
Facility
Modifier
Global
Typical Low
$8.32
Median
$15.49
Typical High
$25.12
UPMC Health Plan
Setting
Professional
Modifier
Global
Typical Low
$3.09
Median
$4.07
Typical High
$4.17
United
Setting
Facility
Modifier
Global
Typical Low
$1.45
Median
$2.00
Typical High
$2.75
United
Setting
Professional
Modifier
Global
Typical Low
$1.51
Median
$2.14
Typical High
$4.27