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Utah rates for HCPCS L4631

Ankle-foot orthosis (AFO), walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$685.43 / $685.43 / $685.43
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$685.43 / $800.11 / $6,385.91
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,037.25 / $1,037.25 / $1,037.25
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$757.19 / $1,037.25 / $1,105.76
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.00 / $1,223.90 / $1,591.07
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,468.02 / $1,637.23 / $1,637.23
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$932.30 / $1,173.56 / $1,760.35
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$648.42 / $828.14 / $995.99