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Alaska rates for HCPCS L6695

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$733.34 / $733.34 / $733.34
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$564.36 / $564.36 / $564.36
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$411.98 / $564.36 / $581.29
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$215.25 / $215.25 / $215.25
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$680.62 / $795.59 / $1,256.19
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$215.25 / $215.25 / $564.36
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$411.98 / $581.29 / $839.58
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$417.80 / $417.80 / $800.79