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Wisconsin rates for HCPCS L8002

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.47 / $100.47 / $100.47
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$83.43 / $100.47 / $168.35
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$199.17 / $219.09 / $362.49
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$172.26 / $185.23 / $244.97
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$143.28 / $426.22 / $426.22
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$120.62 / $439.82 / $831.34
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$88.05 / $288.75 / $376.94
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$57.30 / $150.71 / $229.05
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$114.04 / $194.38 / $239.00
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$99.19 / $199.17 / $927.48
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$89.72 / $133.08 / $216.87
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $65.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$57.30 / $150.71 / $229.05
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$114.04 / $194.38 / $239.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$199.17 / $306.52 / $532.96
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$120.62 / $389.00 / $927.48
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$88.05 / $120.62 / $1,002.77
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$199.17 / $199.17 / $199.17
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$199.17 / $199.17 / $199.17
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$69.50 / $118.35 / $199.17