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Pennsylvania 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
Facility
Modifier
Low / Median / High Price
$376.57 / $376.57 / $1,457.33
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$313.86 / $398.72 / $505.64
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,000.00 / $8,639.91 / $79,506.39
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$642.09 / $843.24 / $843.24
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$528.74 / $528.74 / $802.02
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$385.98 / $385.98 / $702.28
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$737.86 / $802.02 / $1,523.84
Highmark BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$569.41 / $569.41 / $569.41
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$376.57 / $376.57 / $1,457.33
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$313.86 / $398.72 / $607.60
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$994.40 / $1,143.59 / $1,580.10
Priority Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$528.74 / $528.74 / $802.02
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$385.98 / $385.98 / $1,099.88
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$602.89 / $802.61 / $802.61
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$602.89 / $802.61 / $903.12
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$393.73 / $475.28 / $736.76