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Michigan rates for HCPCS L6895

Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$460.42 / $460.42 / $460.42
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$383.68 / $460.42 / $460.42
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,220.25 / $2,431.21 / $4,428.03
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$765.90 / $806.21 / $1,088.38
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$482.96 / $488.15 / $524.04
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$644.97 / $644.97 / $644.97
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$418.79 / $418.79 / $418.79
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$418.79 / $418.79 / $934.50
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$460.42 / $582.58 / $582.58
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$434.32 / $582.58 / $846.52
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$507.11 / $596.60 / $686.09
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$306.73 / $306.73 / $306.73
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$278.63 / $385.41 / $557.26