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Hawaii 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
$245.60 / $245.60 / $245.60
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$776.68 / $776.68 / $776.68
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$564.36 / $564.36 / $1,075.43
HMSA
Facility/Professional
Professional
Modifier
Low / Median / High Price
$977.66 / $1,023.73 / $1,023.73
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$586.60 / $977.66 / $1,368.72
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$468.37 / $776.68 / $1,075.43
University Health Alliance
Facility/Professional
Professional
Modifier
Low / Median / High Price
$787.55 / $814.54 / $930.56