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Utah 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
$10.96 / $10.96 / $10.96
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.48 / $28.18 / $194.98
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$28.84 / $28.84 / $28.84
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21.38 / $21.38 / $31.62
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $35.48 / $60.26
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$33.88 / $39.81 / $67.61
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.99 / $32.36 / $47.86
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$39.81 / $45.71 / $45.71
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.90 / $45.71 / $54.95
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$17.78 / $22.91 / $30.90
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.85 / $19.05 / $25.70