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Utah rates for HCPCS L1990

Ankle-foot orthosis (AFO), double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar 'BK' orthosis), custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$162.18 / $162.18 / $162.18
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$162.18 / $281.84 / $2,884.03
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$316.23 / $316.23 / $316.23
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$229.09 / $229.09 / $331.13
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $363.08 / $478.63
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$371.54 / $436.52 / $758.58
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$281.84 / $354.81 / $549.54
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$446.68 / $501.19 / $645.65
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$363.08 / $512.86 / $758.58
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$208.93 / $251.19 / $398.11
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$194.98 / $251.19 / $363.08