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Utah rates for HCPCS L5655

Addition to lower extremity, socket insert, below knee (BK) (Kemblo, Pelite, Aliplast, Plastazote or equal)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$102.33 / $102.33 / $102.33
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$102.33 / $190.55 / $1,862.09
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$218.78 / $218.78 / $218.78
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$162.18 / $162.18 / $234.42
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $234.42 / $302.00
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$234.42 / $281.84 / $478.63
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$177.83 / $229.09 / $363.08
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$288.40 / $316.23 / $426.58
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$234.42 / $323.59 / $478.63
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$131.83 / $208.93 / $239.88
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$123.03 / $158.49 / $239.88