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Minnesota 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
$662.27 / $662.27 / $662.27
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$326.54 / $588.53 / $662.27
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$677.32 / $790.68 / $1,101.00
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$632.54 / $751.15 / $790.68
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$564.36 / $2,439.46 / $6,775.42
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$916.50 / $971.49 / $1,163.96
Health Partners
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,448.28 / $2,317.91 / $5,334.98
Health Partners
Facility/Professional
Professional
Modifier
Low / Median / High Price
$916.50 / $916.50 / $943.20
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$221.71 / $790.68 / $3,490.81
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$222.28 / $372.87 / $793.99
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$222.28 / $372.87 / $793.99