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Hawaii rates for HCPCS L5703

Ankle, Symes, molded to patient model, socket without solid ankle cushion heel (SACH) foot, replacement only

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,025.97 / $1,025.97 / $1,025.97
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,430.67 / $2,430.67 / $2,430.67
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,119.51 / $2,119.51 / $3,365.70
HMSA
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,059.73 / $3,203.90 / $3,203.90
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,835.84 / $3,059.73 / $4,283.62
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,916.79 / $3,029.13 / $3,365.70
University Health Alliance
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,464.73 / $2,549.19 / $2,912.30