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Michigan rates for HCPCS L8000

Breast Prosthesis Mastectomy Bra Without Integrated Breast Prosthesis Form Any Size Any Type (Revised 01012013)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$29.19 / $186.73 / $454.61
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21.69 / $29.19 / $29.19
Ambetter
Facility/Professional
Professional
Modifier
Low / Median / High Price
$36.93 / $38.33 / $38.34
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$77.36 / $154.13 / $280.72
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$48.55 / $51.11 / $69.00
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$28.48 / $43.82 / $75.91
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.89 / $66.44 / $73.91
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$29.97 / $35.00 / $35.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.97 / $35.00 / $59.25
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$29.71 / $167.08 / $454.61
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.02 / $36.93 / $53.66
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$31.01 / $37.82 / $43.49
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$18.22 / $24.43 / $36.58