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Wisconsin rates for HCPCS L8001

Breast Prosthesis Mastectomy Bra With Integratedbreast Prosthesis Form Unilateral Any Size Any Type (Revised 01012013)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$76.40 / $76.40 / $76.40
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.42 / $76.40 / $127.97
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$151.46 / $166.61 / $275.66
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$130.99 / $140.86 / $186.29
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$108.95 / $324.12 / $324.12
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$98.15 / $334.61 / $632.60
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$71.65 / $219.38 / $286.64
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$43.56 / $114.60 / $174.18
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$86.71 / $147.81 / $181.75
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.42 / $151.46 / $705.18
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$68.22 / $101.19 / $164.92
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $65.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$43.56 / $114.60 / $174.18
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$86.71 / $147.81 / $181.75
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$151.46 / $233.08 / $404.49
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$98.15 / $295.82 / $705.18
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$71.65 / $98.15 / $762.34
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$151.46 / $151.46 / $151.46
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$151.46 / $151.46 / $151.46
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.34 / $100.74 / $151.46