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Montana 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
$651.95 / $2,261.26 / $2,261.26
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$740.03 / $740.03 / $740.03
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$564.36 / $795.68 / $795.68
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$564.36 / $795.68 / $795.68
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$372.61 / $757.79 / $795.68
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$564.36 / $597.20 / $796.26
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$301.35 / $333.42 / $528.80