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Vermont 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
$363.08 / $478.63 / $537.03
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$524.81 / $524.81 / $524.81
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$389.05 / $389.05 / $524.81
MVP Health Care
Facility/Professional
Professional
Modifier
Low / Median / High Price
$741.31 / $776.25 / $1,071.52
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$524.81 / $524.81 / $630.96
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$331.13 / $707.95 / $1,995.26