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Utah rates for HCPCS L5704

Custom Shaped Protective Cover Below Knee

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$203.55 / $203.55 / $203.55
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$203.55 / $237.13 / $2,111.69
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$394.91 / $394.91 / $394.91
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$288.27 / $394.90 / $420.99
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$321.68 / $518.85 / $674.50
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$622.34 / $694.07 / $694.07
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$395.23 / $497.51 / $746.27
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$284.68 / $315.29 / $452.33