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Pennsylvania 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
$295.12 / $1,122.02 / $1,122.02
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$281.84 / $331.13 / $562.34
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,011.87 / $8,511.38 / $77,624.71
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$660.69 / $660.69 / $660.69
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$436.52 / $436.52 / $660.69
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$316.23 / $316.23 / $436.52
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$616.60 / $870.96 / $1,258.93
Geisinger
Facility/Professional
Facility
Modifier
Low / Median / High Price
$660.69 / $660.69 / $660.69
Geisinger
Facility/Professional
Professional
Modifier
Low / Median / High Price
$398.11 / $467.74 / $660.69
Highmark BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$489.78 / $489.78 / $489.78
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$295.12 / $295.12 / $1,122.02
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$288.40 / $338.84 / $588.84
Oscar Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,071.52 / $1,071.52 / $1,071.52
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.60 / $933.25 / $1,288.25
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$467.74 / $467.74 / $616.60
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$467.74 / $575.44 / $645.65
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$269.15 / $812.83 / $977.24
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$295.12 / $354.81 / $588.84