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Maine rates for HCPCS L7404

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$295.12 / $338.84 / $1,000.00
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$645.65 / $776.25 / $891.25
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$407.38 / $407.38 / $660.69
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$436.52 / $436.52 / $436.52
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$316.23 / $316.23 / $436.52
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$575.44 / $575.44 / $691.83
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$295.12 / $407.38 / $1,000.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$190.55 / $398.11 / $398.11
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$234.42 / $457.09 / $630.96