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Utah rates for HCPCS L5699

All lower extremity prostheses, shoulder harness

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$72.44 / $72.44 / $72.44
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$72.44 / $134.90 / $1,288.25
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$169.82 / $169.82 / $169.82
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$123.03 / $123.03 / $173.78
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $162.18 / $213.80
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$165.96 / $194.98 / $338.84
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$123.03 / $158.49 / $257.04
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$199.53 / $223.87 / $302.00
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$162.18 / $229.09 / $338.84
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$93.33 / $147.91 / $169.82
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$87.10 / $112.20 / $165.96