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South Dakota rates for HCPCS L8001

Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$126.86 / $126.86 / $126.86
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$117.60 / $126.86 / $149.49
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$98.15 / $98.15 / $165.74
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$175.50 / $175.50 / $219.38
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.08 / $160.91 / $705.18
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.99 / $101.83 / $165.25
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$137.81 / $165.74 / $259.61
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$135.74 / $168.07 / $316.72
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$127.69 / $149.49 / $177.70
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$52.84 / $101.83 / $151.46
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$147.66 / $147.66 / $147.66