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Michigan rates for HCPCS L7403

Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$253.90 / $253.90 / $253.90
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$211.59 / $253.90 / $253.90
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$672.91 / $1,340.71 / $2,441.87
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$422.36 / $444.59 / $600.20
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$282.04 / $288.98 / $290.55
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$355.67 / $355.67 / $355.67
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$286.80 / $286.80 / $286.80
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$209.36 / $369.67 / $644.05
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$253.90 / $321.27 / $321.27
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$253.90 / $321.27 / $500.05
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$279.64 / $329.00 / $378.35
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$169.27 / $211.06 / $318.19