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South Dakota rates for HCPCS L8002

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$166.82 / $166.82 / $166.82
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$154.72 / $166.82 / $196.64
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$120.62 / $120.62 / $218.06
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$231.00 / $231.00 / $288.75
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$91.87 / $211.72 / $927.48
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$80.23 / $133.94 / $217.42
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$181.31 / $218.06 / $341.45
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$178.58 / $221.13 / $416.72
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$167.97 / $196.64 / $233.74
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$69.50 / $133.94 / $199.17
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$194.28 / $194.28 / $194.28