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Maine rates for HCPCS L5697

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$42.66 / $56.23 / $199.53
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$125.89 / $151.36 / $173.78
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$57.54 / $57.54 / $131.83
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$60.26 / $60.26 / $95.50
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$43.65 / $43.65 / $60.26
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$112.20 / $112.20 / $134.90
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$44.67 / $61.66 / $199.53
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$30.90 / $63.10 / $67.61
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$42.66 / $72.44 / $112.20