go back

New Hampshire 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
$444.29 / $444.29 / $533.15
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$313.80 / $344.75 / $531.41
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$789.04 / $789.04 / $935.33
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$424.98 / $424.98 / $426.49
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 / $1,971.81
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$262.43 / $393.64 / $663.22
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$590.96 / $650.05 / $827.34