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Virginia 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
$370.60 / $370.60 / $374.54
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$344.57 / $370.60 / $401.40
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$702.69 / $702.69 / $746.26
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$424.98 / $424.98 / $531.26
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$427.48 / $427.48 / $480.35
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
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$491.88 / $632.41 / $843.23
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$215.25 / $432.16 / $799.89
Medcost
Facility/Professional
Professional
Modifier
Low / Median / High Price
$520.40 / $922.99 / $1,170.45
Sentara
Facility/Professional
Facility
Modifier
Low / Median / High Price
$384.98 / $540.20 / $897.72
Sentara
Facility/Professional
Professional
Modifier
Low / Median / High Price
$384.98 / $540.20 / $897.72
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$316.83 / $350.56 / $513.79