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Utah rates for HCPCS L1902

Ankle Orthosis Ankle Gauntlet Or Similiar With Or Without Joints Prefabricated Off-The-Shelf (Revised 01/01/2016)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$38.00 / $59.24 / $68.67
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$28.97 / $56.20 / $236.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$56.94 / $58.00 / $58.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$42.34 / $58.00 / $61.83
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.85 / $65.65 / $85.34
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$78.75 / $87.83 / $87.83
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.01 / $62.95 / $94.43
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$35.13 / $44.47 / $53.96