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Utah rates for HCPCS L5654

Addition to lower extremity, socket insert, Symes, (Kemblo, Pelite, Aliplast, Plastazote or equal)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$128.82 / $128.82 / $128.82
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$128.82 / $218.78 / $2,137.96
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$309.03 / $309.03 / $309.03
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$223.87 / $223.87 / $323.59
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $295.12 / $380.19
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$295.12 / $346.74 / $602.56
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$223.87 / $288.40 / $426.58
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$363.08 / $398.11 / $478.63
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$295.12 / $407.38 / $575.44
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$165.96 / $245.47 / $302.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$154.88 / $199.53 / $295.12