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Below-Knee Prosthesis Protective Cover, Custom-Shaped

Utah rates for HCPCS L5704

Custom shaped protective cover, below knee (BK)

Rates data updated July 2026.

Facilitymedian $363 · 10th–90th $204$7080%20%40%10th90th$363Professionalmedian $398 · 10th–90th $204$3,1620%10%10th90th$398$50.0$100.0$200.0$500.0$1.0K$2.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$204.17
Median
$204.17
Typical High
$204.17
Aetna
Setting
Professional
Modifier
Global
Typical Low
$204.17
Median
$281.84
Typical High
$3,162.28
Cigna
Setting
Facility
Modifier
Global
Typical Low
$398.11
Median
$398.11
Typical High
$398.11
Cigna
Setting
Professional
Modifier
Global
Typical Low
$288.40
Median
$288.40
Typical High
$407.38
Molina
Setting
Professional
Modifier
Global
Typical Low
$60.26
Median
$524.81
Typical High
$676.08
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$676.08
Median
$707.95
Typical High
$707.95
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$398.11
Median
$512.86
Typical High
$812.83
Select Health
Setting
Facility
Modifier
Global
Typical Low
$724.44
Median
$724.44
Typical High
$724.44
Select Health
Setting
Professional
Modifier
Global
Typical Low
$363.08
Median
$707.95
Typical High
$741.31
U of Utah Health Plan
Setting
Professional
Modifier
Global
Typical Low
$512.86
Median
$724.44
Typical High
$891.25
United
Setting
Facility
Modifier
Global
Typical Low
$263.03
Median
$416.87
Typical High
$501.19
United
Setting
Professional
Modifier
Global
Typical Low
$245.47
Median
$316.23
Typical High
$489.78