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Utah rates for HCPCS L7404

Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$194.98 / $194.98 / $194.98
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$194.98 / $346.74 / $2,818.38
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$436.52 / $436.52 / $436.52
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$316.23 / $316.23 / $467.74
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $489.78 / $630.96
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$501.19 / $588.84 / $1,023.29
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$380.19 / $489.78 / $707.95
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$616.60 / $676.08 / $691.83
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$489.78 / $691.83 / $794.33
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$251.19 / $398.11 / $446.68
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$234.42 / $302.00 / $446.68