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Indiana 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
Facility
Modifier
Low / Median / High Price
$376.29 / $376.29 / $790.68
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$351.99 / $376.29 / $391.34
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$624.64 / $707.66 / $790.68
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$396.13 / $424.98 / $573.72
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$593.01 / $869.75 / $1,106.95
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$672.08 / $869.75 / $1,067.42
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$564.36 / $564.36 / $790.68
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$411.98 / $564.36 / $811.09
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$222.28 / $394.46 / $558.82