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Michigan rates for HCPCS L4631

Ankle Foot Orthosis Walking Boot Type Varus/ Valgus Correction Rocker Bottom Anterior Tibial Shell Soft Interface Custom Arch Support Plastic Or Other Material Includes Straps And Closures Custom Fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,014.34 / $1,014.34 / $1,014.34
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$929.81 / $996.99 / $1,014.34
Ambetter
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,332.11 / $1,332.11 / $1,332.11
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,688.31 / $5,356.16 / $9,755.33
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,687.34 / $1,776.15 / $2,397.80
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,154.50 / $1,175.06 / $1,218.83
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,420.92 / $1,420.92 / $1,420.92
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,037.25 / $1,037.25 / $1,037.25
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,037.25 / $1,037.25 / $2,059.13
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,014.34 / $1,283.53 / $1,283.53
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$996.99 / $1,283.53 / $1,864.95
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,117.19 / $1,314.35 / $1,511.50
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$648.42 / $834.08 / $1,333.46