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Montana rates for HCPCS L6895

Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$338.84 / $501.19 / $676.08
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$676.08 / $676.08 / $676.08
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$416.87 / $724.44 / $724.44
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$309.03 / $588.84 / $724.44
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$524.81 / $676.08 / $1,318.26
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$524.81 / $676.08 / $1,318.26
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$363.08 / $630.96 / $954.99
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $537.03 / $724.44
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$446.68 / $501.19 / $524.81
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$302.00 / $331.13 / $512.86