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Utah rates for HCPCS A5501

For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$77.62 / $77.62 / $77.62
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $169.82 / $1,148.15
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$177.83 / $177.83 / $177.83
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$128.82 / $128.82 / $213.80
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $60.26 / $234.42
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$199.53 / $234.42 / $407.38
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$147.91 / $190.55 / $288.40
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$245.47 / $269.15 / $269.15
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$190.55 / $269.15 / $323.59
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$109.65 / $138.04 / $190.55
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$93.33 / $120.23 / $169.82