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Utah rates for HCPCS L5704

Custom shaped protective cover, below knee (BK)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$204.17 / $204.17 / $204.17
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$204.17 / $354.81 / $3,162.28
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$398.11 / $398.11 / $398.11
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$288.40 / $288.40 / $416.87
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $524.81 / $676.08
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$524.81 / $616.60 / $1,071.52
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$398.11 / $512.86 / $758.58
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$645.65 / $707.95 / $741.31
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$524.81 / $724.44 / $891.25
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$263.03 / $416.87 / $478.63
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$245.47 / $316.23 / $467.74