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Utah rates for HCPCS L5857

Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,951.21 / $2,951.21 / $2,951.21
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,951.21 / $5,370.32 / $43,651.58
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6,606.93 / $6,606.93 / $6,606.93
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,897.79 / $4,897.79 / $6,918.31
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $7,585.78 / $9,772.37
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$7,762.47 / $9,120.11 / $15,848.93
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,754.40 / $7,413.10 / $10,715.19
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$9,332.54 / $10,471.29 / $10,471.29
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$7,585.78 / $10,471.29 / $12,302.69
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,801.89 / $6,025.60 / $6,918.31
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,630.78 / $4,570.88 / $6,918.31