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Utah rates for HCPCS L6895

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$213.80 / $213.80 / $213.80
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$213.80 / $398.11 / $2,884.03
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$416.87 / $416.87 / $416.87
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$309.03 / $309.03 / $446.68
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $501.19 / $645.65
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$512.86 / $602.56 / $1,047.13
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$380.19 / $489.78 / $741.31
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$616.60 / $691.83 / $741.31
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$501.19 / $691.83 / $912.01
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$281.84 / $338.84 / $501.19
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$263.03 / $331.13 / $501.19