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Utah rates for HCPCS L6628

Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$185.18 / $185.18 / $185.18
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$185.18 / $186.28 / $1,658.94
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$444.49 / $444.49 / $444.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$324.48 / $444.49 / $457.82
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$346.98 / $559.66 / $727.55
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$671.29 / $748.67 / $748.67
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$426.31 / $536.64 / $804.96
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$108.00 / $108.00 / $108.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$259.00 / $286.85 / $411.52