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New Hampshire rates for HCPCS L5655

Addition to lower extremity, socket insert, below knee (BK) (Kemblo, Pelite, Aliplast, Plastazote or equal)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$213.33 / $213.33 / $256.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$150.51 / $178.24 / $239.25
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$378.89 / $378.89 / $449.14
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$201.58 / $201.58 / $203.16
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$221.07 / $221.07 / $221.07
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$161.38 / $161.38 / $235.67
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$306.77 / $306.77 / $946.85
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$126.02 / $189.02 / $239.01
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$283.77 / $312.16 / $397.29