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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
$6,455.32 / $6,455.32 / $6,455.32
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6,455.32 / $7,094.78 / $63,182.40
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14,513.81 / $14,513.81 / $14,513.81
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10,595.08 / $14,513.81 / $15,472.44
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10,266.35 / $16,558.64 / $21,526.23
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$19,861.41 / $22,150.67 / $22,150.67
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12,613.36 / $15,877.60 / $23,816.40
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$9,028.41 / $9,999.21 / $14,345.15