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Utah rates for HCPCS L8015

External breast prosthesis garment, with mastectomy form, post mastectomy

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$19.95 / $19.95 / $19.95
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21.88 / $38.02 / $309.03
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$46.77 / $46.77 / $46.77
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$33.88 / $33.88 / $50.12
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$34.67 / $53.70 / $69.18
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$54.95 / $64.57 / $112.20
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.74 / $52.48 / $77.62
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$66.07 / $72.44 / $74.13
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.70 / $74.13 / $89.13
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.92 / $37.15 / $42.66
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.12 / $32.36 / $46.77