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Michigan rates for HCPCS L6695

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$451.55 / $451.55 / $451.55
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$374.12 / $451.55 / $451.55
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,196.74 / $2,384.37 / $4,342.72
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$751.15 / $790.68 / $1,067.42
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$456.75 / $462.26 / $513.94
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$632.54 / $632.54 / $632.54
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$564.36 / $564.36 / $564.36
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$411.98 / $564.36 / $916.50
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$451.55 / $571.39 / $571.39
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$451.55 / $571.39 / $889.31
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$497.33 / $585.10 / $672.86
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$277.85 / $378.00 / $565.90