go back

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
$64.12 / $64.12 / $64.12
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.15 / $64.12 / $64.12
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$169.94 / $338.59 / $616.69
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$106.67 / $112.28 / $151.58
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$62.63 / $65.91 / $72.98
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$89.82 / $89.82 / $89.82
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$60.21 / $60.21 / $60.21
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.21 / $60.21 / $130.13
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.12 / $81.15 / $81.15
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.44 / $81.15 / $117.89
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$68.13 / $83.09 / $95.55
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.06 / $53.68 / $76.75