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Pennsylvania rates for HCPCS A5504

For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$22.16 / $22.16 / $35.18
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.10 / $27.70 / $36.17
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,000.00 / $8,639.91 / $79,506.39
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$34.45 / $45.26 / $45.26
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$29.14 / $29.14 / $29.14
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21.27 / $21.27 / $52.50
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$41.64 / $45.26 / $85.99
Highmark BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.38 / $29.38 / $33.95
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$22.16 / $22.16 / $35.18
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$18.34 / $27.70 / $42.74
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.70 / $61.70 / $89.00
Priority Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$29.14 / $29.14 / $29.14
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21.27 / $21.27 / $53.03
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$31.18 / $43.06 / $43.06
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$31.18 / $43.06 / $43.06
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17.80 / $23.09 / $40.72