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Vermont 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
$247.64 / $247.64 / $285.74
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$366.26 / $366.26 / $372.99
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$267.37 / $345.63 / $390.45
MVP Health Care
Facility/Professional
Facility
Modifier
Low / Median / High Price
$366.26 / $366.26 / $372.99
MVP Health Care
Facility/Professional
Professional
Modifier
Low / Median / High Price
$267.37 / $366.26 / $390.45
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$168.78 / $328.04 / $586.66