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Wisconsin 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
$406.70 / $406.70 / $406.70
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$312.85 / $406.70 / $675.28
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$806.21 / $886.83 / $1,467.30
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$697.29 / $749.78 / $991.63
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$579.98 / $1,725.29 / $1,725.29
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$418.79 / $1,666.97 / $3,364.55
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.72 / $1,168.13 / $1,525.81
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$215.86 / $610.04 / $927.14
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$461.60 / $670.20 / $967.45
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$373.66 / $806.21 / $3,451.92
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$363.14 / $503.66 / $877.86
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $70.00 / $486.13
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$215.86 / $610.04 / $927.14
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$461.60 / $670.20 / $967.45
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$806.21 / $1,240.70 / $2,006.40
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$418.79 / $1,574.62 / $3,451.92
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.72 / $418.79 / $3,683.44
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$806.21 / $806.21 / $806.21
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$806.21 / $806.21 / $806.21
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$306.73 / $306.73 / $306.73
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$278.63 / $483.73 / $714.80