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Utah rates for HCPCS L7400

Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultra-light material (titanium, carbon fiber or equal)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$107.15 / $107.15 / $107.15
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$107.15 / $190.55 / $1,584.89
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$239.88 / $239.88 / $239.88
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$173.78 / $173.78 / $257.04
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $275.42 / $346.74
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$275.42 / $331.13 / $562.34
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$208.93 / $269.15 / $389.05
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$338.84 / $371.54 / $380.19
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$275.42 / $380.19 / $446.68
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$138.04 / $218.78 / $251.19
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$128.82 / $165.96 / $245.47