go back

Montana rates for HCPCS L6694

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$782.34 / $2,713.54 / $2,713.54
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$888.09 / $888.09 / $888.09
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$528.74 / $954.87 / $954.87
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$528.74 / $954.87 / $954.87
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$447.14 / $909.40 / $954.87
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$528.74 / $716.67 / $955.56
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$361.63 / $400.12 / $634.59