L6895
Prosthetics & Orthotics
53 States
Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated
Short Desc
Custom glove for term device
Coverage determined by local carrier discretion.
Added Date
1986-01-01
Effective From
2005-01-01
National Floor
$683.61
National Ceiling
$911.47
Fee Schedule Rates
Effective Jan 2026Official Medicare DMEPOS pricing for 2026.
| State | Modifier | Non-Rural | Rural |
|---|---|---|---|
|
AK
|
Base Rate |
$651.37
|
Same |
|
AL
|
Base Rate |
$766.02
|
Same |
|
AR
|
Base Rate |
$683.61
|
Same |
|
AZ
|
Base Rate |
$683.61
|
Same |
|
CA
|
Base Rate |
$683.61
|
Same |
|
CO
|
Base Rate |
$698.69
|
Same |
|
CT
|
Base Rate |
$911.47
|
Same |
|
DC
|
Base Rate |
$757.88
|
Same |
|
DE
|
Base Rate |
$757.88
|
Same |
|
FL
|
Base Rate |
$766.02
|
Same |
|
GA
|
Base Rate |
$766.02
|
Same |
|
HI
|
Base Rate |
$696.49
|
Same |
|
IA
|
Base Rate |
$782.99
|
Same |
|
ID
|
Base Rate |
$759.01
|
Same |
|
IL
|
Base Rate |
$822.33
|
Same |
|
IN
|
Base Rate |
$822.33
|
Same |
|
KS
|
Base Rate |
$782.99
|
Same |
|
KY
|
Base Rate |
$766.02
|
Same |
|
LA
|
Base Rate |
$683.61
|
Same |
|
MA
|
Base Rate |
$911.47
|
Same |
|
MD
|
Base Rate |
$757.88
|
Same |
|
ME
|
Base Rate |
$911.47
|
Same |
|
MI
|
Base Rate |
$822.33
|
Same |
|
MN
|
Base Rate |
$822.33
|
Same |
|
MO
|
Base Rate |
$782.99
|
Same |
|
MS
|
Base Rate |
$766.02
|
Same |
|
MT
|
Base Rate |
$698.69
|
Same |
|
NC
|
Base Rate |
$766.02
|
Same |
|
ND
|
Base Rate |
$698.69
|
Same |
|
NE
|
Base Rate |
$782.99
|
Same |
|
NH
|
Base Rate |
$911.47
|
Same |
|
NJ
|
Base Rate |
$683.61
|
Same |
|
NM
|
Base Rate |
$683.61
|
Same |
|
NV
|
Base Rate |
$683.61
|
Same |
|
NY
|
Base Rate |
$683.61
|
Same |
|
OH
|
Base Rate |
$822.33
|
Same |
|
OK
|
Base Rate |
$683.61
|
Same |
|
OR
|
Base Rate |
$759.01
|
Same |
|
PA
|
Base Rate |
$757.88
|
Same |
|
PR
|
Base Rate |
$327.22
|
Same |
|
RI
|
Base Rate |
$911.47
|
Same |
|
SC
|
Base Rate |
$766.02
|
Same |
|
SD
|
Base Rate |
$698.69
|
Same |
|
TN
|
Base Rate |
$766.02
|
Same |
|
TX
|
Base Rate |
$683.61
|
Same |
|
UT
|
Base Rate |
$698.69
|
Same |
|
VA
|
Base Rate |
$757.88
|
Same |
|
VI
|
Base Rate |
$683.61
|
Same |
|
VT
|
Base Rate |
$911.47
|
Same |
|
WA
|
Base Rate |
$759.01
|
Same |
|
WI
|
Base Rate |
$822.33
|
Same |
|
WV
|
Base Rate |
$757.88
|
Same |
|
WY
|
Base Rate |
$698.69
|
Same |