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Utah rates for HCPCS L5858

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6,456.54 / $6,456.54 / $6,456.54
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6,456.54 / $11,748.98 / $95,499.26
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14,454.40 / $14,454.40 / $14,454.40
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10,715.19 / $10,715.19 / $15,488.17
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $16,595.87 / $21,379.62
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$16,982.44 / $19,952.62 / $34,673.69
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12,589.25 / $16,218.10 / $23,442.29
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$20,417.38 / $22,908.68 / $22,908.68
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$16,595.87 / $22,908.68 / $26,915.35
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$8,317.64 / $13,182.57 / $15,135.61
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$7,762.47 / $10,000.00 / $15,135.61