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Maine rates for HCPCS L5658

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$194.98 / $263.03 / $776.25
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$501.19 / $602.56 / $691.83
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$269.15 / $269.15 / $512.86
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$354.81 / $363.08 / $371.54
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$269.15 / $269.15 / $363.08
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$446.68 / $446.68 / $537.03
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$204.17 / $295.12 / $776.25
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$138.04 / $223.87 / $288.40
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$169.82 / $331.13 / $467.74