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Vermont 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
Professional
Modifier
Low / Median / High Price
$302.00 / $398.11 / $446.68
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$562.34 / $562.34 / $562.34
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$407.38 / $407.38 / $562.34
MVP Health Care
Facility/Professional
Professional
Modifier
Low / Median / High Price
$616.60 / $645.65 / $891.25
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$436.52 / $436.52 / $524.81
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$275.42 / $588.84 / $1,659.59