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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
$31.03 / $31.03 / $31.03
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$31.03 / $41.62 / $370.67
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$60.21 / $60.21 / $60.21
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$43.95 / $60.21 / $64.19
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$47.69 / $76.65 / $99.64
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$91.93 / $102.53 / $102.53
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$58.38 / $73.48 / $110.24
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$43.40 / $48.07 / $68.95