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Arizona 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
$318.14 / $352.67 / $529.30
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$205.75 / $743.28 / $1,343.82
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$514.39 / $685.85 / $934.47
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 / $411.98 / $916.50
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$215.25 / $392.66 / $3,490.81
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$301.35 / $333.42 / $513.79
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$301.35 / $333.42 / $502.25