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Washington 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
$32.19 / $73.06 / $115.90
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$14.53 / $32.19 / $55.69
Ambetter
Facility/Professional
Professional
Modifier
Low / Median / High Price
$37.15 / $37.15 / $49.53
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$42.10 / $99.62 / $230.54
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$33.81 / $44.10 / $314.95
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$29.97 / $35.00 / $35.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.55 / $25.55 / $35.00
Kaiser Permanente
Facility/Professional
Facility
Modifier
Low / Median / High Price
$27.75 / $49.53 / $125.62
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$27.78 / $49.53 / $92.68
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$34.18 / $37.97 / $41.77
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$39.34 / $45.16 / $49.53
Pacific Source
Facility/Professional
Professional
Modifier
Low / Median / High Price
$44.58 / $49.53 / $49.53
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$32.13 / $55.63 / $96.74
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.13 / $55.00 / $69.98
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$47.14 / $48.37 / $48.37
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$39.36 / $42.10 / $54.48
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$20.84 / $32.93 / $41.71
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$28.04 / $28.04 / $42.10