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Utah rates for HCPCS L5697

Addition to lower extremity, above knee (AK) or knee disarticulation, pelvic band

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$30.90 / $30.90 / $30.90
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.90 / $54.95 / $562.34
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$60.26 / $60.26 / $60.26
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$43.65 / $43.65 / $64.57
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$47.86 / $75.86 / $100.00
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$77.62 / $91.20 / $158.49
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$58.88 / $74.13 / $112.20
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$93.33 / $104.71 / $131.83
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.86 / $107.15 / $158.49
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$39.81 / $64.57 / $72.44
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$38.02 / $47.86 / $72.44