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Texas 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
$295.33 / $295.33 / $318.95
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$295.33 / $318.95 / $590.65
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$321.02 / $321.02 / $401.64
Christus
Facility/Professional
Facility
Modifier
Low / Median / High Price
$674.54 / $674.54 / $674.54
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$434.07 / $434.07 / $434.07
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$316.87 / $316.87 / $434.07
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,127.33 / $3,124.60 / $3,124.60
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,378.23 / $3,378.23 / $4,911.89
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$193.05 / $506.41 / $674.54
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$195.23 / $607.09 / $674.54
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$193.05 / $450.71 / $674.54
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$316.87 / $316.87 / $485.72
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$249.20 / $368.65 / $450.71
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$362.71 / $403.13 / $674.54