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Illinois rates for HCPCS L7404

Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.13 / $331.13 / $691.83
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$288.40 / $346.74 / $660.69
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$812.83 / $1,288.25 / $4,677.35
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$512.86 / $512.86 / $512.86
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$436.52 / $436.52 / $741.31
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$316.23 / $316.23 / $741.31
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$575.44 / $776.25 / $977.24
Hally Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$870.96 / $870.96 / $870.96
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$398.11 / $537.03 / $977.24
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$257.04 / $331.13 / $512.86