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Ohio 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
$386.08 / $386.08 / $938.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$344.57 / $386.08 / $506.34
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$742.45 / $869.75 / $2,253.44
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$396.13 / $424.98 / $1,027.88
Aultcare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$672.08 / $672.08 / $672.08
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$533.38 / $790.68 / $1,067.42
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$513.94 / $711.61 / $1,693.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$564.36 / $564.36 / $857.79
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$411.98 / $411.98 / $657.44
Medical Mutual of Ohio
Facility/Professional
Facility
Modifier
Low / Median / High Price
$564.36 / $564.36 / $564.36
Medical Mutual of Ohio
Facility/Professional
Professional
Modifier
Low / Median / High Price
$411.98 / $564.36 / $564.36
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$262.98 / $394.46 / $513.79