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Utah rates for HCPCS L5628

Addition to lower extremity, test socket, hemipelvectomy

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$186.21 / $186.21 / $186.21
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$186.21 / $323.59 / $2,511.89
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$501.19 / $501.19 / $501.19
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$363.08 / $363.08 / $512.86
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $426.58 / $549.54
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$426.58 / $512.86 / $870.96
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$323.59 / $416.87 / $630.96
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$524.81 / $575.44 / $724.44
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$426.58 / $588.84 / $870.96
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$229.09 / $288.40 / $436.52
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$223.87 / $288.40 / $436.52