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Utah rates for HCPCS L3675

Shoulder Orthosis Vest Type Abduction Restrainer Canvas Webbing Type Or Equal Prefabricated Off- The-Shelf (Revised 01/01/14)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$55.36 / $55.36 / $55.36
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$55.36 / $64.14 / $541.91
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$107.42 / $107.42 / $153.94
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$78.42 / $107.42 / $153.94
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$88.03 / $141.99 / $184.58
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$170.31 / $189.94 / $189.94
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$108.17 / $136.15 / $204.23
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$71.47 / $85.76 / $91.26
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$67.15 / $85.76 / $100.73