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Michigan rates for HCPCS L5697

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.57 / $64.57 / $64.57
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$41.69 / $54.95 / $85.11
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$141.25 / $338.84 / $645.65
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$107.15 / $112.20 / $117.49
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$63.10 / $63.10 / $63.10
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$60.26 / $60.26 / $60.26
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$43.65 / $60.26 / $131.83
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.57 / $213.80 / $239.88
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$52.48 / $89.13 / $138.04
Priority Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$60.26 / $60.26 / $60.26
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$43.65 / $60.26 / $64.57
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$63.10 / $89.13 / $131.83
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$39.81 / $53.70 / $75.86