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Utah rates for HCPCS L1630

Hip orthosis (HO), abduction control of hip joints, semi-flexible (Von Rosen type), custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$61.66 / $61.66 / $61.66
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$61.66 / $107.15 / $912.01
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$120.23 / $120.23 / $120.23
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$87.10 / $87.10 / $123.03
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $138.04 / $181.97
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$141.25 / $165.96 / $288.40
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$107.15 / $134.90 / $204.17
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$169.82 / $190.55 / $208.93
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.04 / $194.98 / $251.19
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$79.43 / $95.50 / $125.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$74.13 / $95.50 / $138.04