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Pennsylvania rates for HCPCS L5681

Addition To Lower Extremity Below Knee/Above Knee Custom Fabricated Socketinsert For Congenital Or Atypical Traumatic Amputee Silicone Gel Elastomericor Equal For Use With Or Without Locking Mechanism Initial Only (For Other Than Initial Use Code L5673 Or L5679)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$692.14 / $692.14 / $2,678.58
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$606.53 / $732.86 / $944.43
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,000.00 / $8,639.91 / $79,506.39
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,180.17 / $1,549.90 / $1,549.90
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$886.63 / $886.63 / $1,549.90
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$647.24 / $647.24 / $1,357.14
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,425.91 / $1,549.90 / $2,944.81
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$692.14 / $692.14 / $2,678.58
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$606.53 / $732.86 / $1,259.69
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,921.70 / $2,209.90 / $3,053.60
Priority Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$886.63 / $886.63 / $1,549.90
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$647.24 / $647.24 / $1,840.88
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,108.09 / $1,475.21 / $1,475.21
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,108.09 / $1,475.21 / $1,511.46
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$707.89 / $837.66 / $1,288.70