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Utah rates for HCPCS L7403

Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$125.89 / $125.89 / $125.89
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $229.09 / $1,905.46
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$288.40 / $288.40 / $288.40
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$208.93 / $208.93 / $309.03
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $331.13 / $416.87
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.13 / $389.05 / $676.08
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 / $446.68 / $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 / $295.12
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$154.88 / $199.53 / $295.12