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Maine 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
$344.75 / $531.41 / $531.41
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$701.77 / $909.21 / $1,685.39
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$424.98 / $426.49 / $592.38
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 / $564.36
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$638.85 / $638.85 / $638.85
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$444.29 / $531.41 / $531.41
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$262.43 / $510.22 / $905.25