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Virginia 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
$1,324.17 / $1,324.17 / $1,338.27
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,231.16 / $1,324.17 / $1,512.58
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,510.75 / $2,510.75 / $2,666.42
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,526.81 / $1,526.81 / $1,967.98
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,346.20 / $1,346.20 / $1,716.33
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
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,757.53 / $2,259.67 / $3,012.90
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$808.65 / $1,544.15 / $2,817.10
Medcost
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,978.61 / $3,297.88 / $4,182.10
Sentara
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,375.56 / $1,930.19 / $3,207.63
Sentara
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,375.56 / $1,930.19 / $3,207.63
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,158.10 / $1,252.58 / $1,930.19