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New Hampshire 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
Facility
Modifier
Low / Median / High Price
$1,597.78 / $1,597.78 / $1,917.34
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,121.24 / $1,239.83 / $1,597.78
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,837.63 / $2,837.63 / $3,363.73
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,526.81 / $1,526.81 / $1,602.21
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,119.51 / $2,119.51 / $2,119.51
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,547.24 / $1,547.24 / $2,119.51
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,297.51 / $2,297.51 / $7,091.26
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$943.78 / $1,415.66 / $2,297.51
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,125.29 / $2,337.82 / $2,975.41