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Michigan rates for HCPCS L5696

Addition to lower extremity, above knee (AK) or knee disarticulation, pelvic joint

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$135.03 / $135.03 / $135.03
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$115.45 / $135.03 / $138.32
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$357.87 / $713.01 / $1,298.61
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$224.62 / $236.44 / $319.19
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$144.35 / $153.69 / $162.26
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$189.15 / $189.15 / $189.15
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$138.76 / $138.76 / $138.76
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.76 / $138.76 / $274.13
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$135.03 / $170.87 / $170.87
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$133.79 / $170.87 / $248.26
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$143.47 / $174.97 / $201.21
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$251.68 / $296.08 / $296.08
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$92.33 / $113.04 / $170.72