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Michigan rates for HCPCS A4220

Refill Kit For Implantable Infusion Pump (Special Coverage Instructions Apply. See Cim: 60-14)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$20.00 / $20.00 / $20.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.00 / $20.00 / $20.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3.60 / $3.60 / $73.48
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.94 / $11.94 / $20.00
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.94 / $13.73 / $22.50
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$73.48 / $73.48 / $1,500.00