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New Jersey 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
$245.60 / $245.60 / $245.60
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$245.60 / $313.80 / $477.82
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$564.36 / $564.36 / $668.33
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$411.98 / $411.98 / $585.21
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$610.57 / $614.86 / $875.51
Horizon BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$652.66 / $668.33 / $668.33
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$306.87 / $350.56 / $668.33