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Utah rates for HCPCS L7402

Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultra-light material (titanium, carbon fiber or equal)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$128.82 / $128.82 / $128.82
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$128.82 / $234.42 / $1,905.46
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$316.23 / $316.23 / $316.23
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$234.42 / $234.42 / $338.84
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $331.13 / $426.58
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$338.84 / $398.11 / $691.83
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$251.19 / $323.59 / $467.74
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$407.38 / $457.09 / $457.09
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$331.13 / $457.09 / $537.03
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$165.96 / $263.03 / $302.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$154.88 / $199.53 / $302.00