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North Carolina 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
$529.30 / $529.30 / $1,074.24
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$318.14 / $529.30 / $529.30
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$570.19 / $684.23 / $1,299.15
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$495.12 / $533.38 / $533.38
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 / $564.36 / $916.50
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$215.25 / $529.30 / $792.99
Medcost
Facility/Professional
Professional
Modifier
Low / Median / High Price
$520.40 / $520.40 / $520.40
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$802.00 / $802.00 / $1,233.09
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$277.85 / $356.30 / $556.61
Wellcare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,328.34 / $3,722.67 / $3,722.67
Wellcare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,773.79 / $5,012.47 / $5,012.47