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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
$186.21 / $263.03 / $354.81
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$363.08 / $363.08 / $371.54
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$269.15 / $269.15 / $363.08
MVP Health Care
Facility/Professional
Professional
Modifier
Low / Median / High Price
$398.11 / $457.09 / $575.44
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$165.96 / $223.87 / $346.74
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$173.78 / $380.19 / $1,047.13