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Utah rates for HCPCS L3677

Shoulder Orthosis Shoulder Joint Design Without Joints May Include Soft Interface Straps Pre- Fabricated Item That Has Been Trimmed Bent Molded Assembled Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise(Revised 01/01/14)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$46.30 / $46.30 / $46.30
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$36.04 / $46.30 / $76.18
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.05 / $75.05 / $75.05
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$54.79 / $54.79 / $102.26
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$35.00 / $45.00 / $80.00
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$114.66 / $127.10 / $162.86
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$97.19 / $97.19 / $97.19
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$48.78 / $57.82 / $70.45