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Utah rates for HCPCS L5658

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$141.25 / $141.25 / $141.25
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$141.25 / $251.19 / $1,949.84
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$363.08 / $363.08 / $363.08
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$269.15 / $269.15 / $389.05
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $363.08 / $478.63
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$371.54 / $436.52 / $758.58
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$275.42 / $354.81 / $537.03
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$446.68 / $501.19 / $575.44
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$363.08 / $512.86 / $707.95
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$165.96 / $223.87 / $331.13
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$169.82 / $218.78 / $323.59