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South Dakota rates for HCPCS L8015

External breast prosthesis garment, with mastectomy form, post mastectomy

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$60.61 / $60.61 / $60.61
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21.49 / $56.19 / $71.45
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$46.82 / $47.76 / $79.19
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$84.00 / $84.00 / $105.00
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$53.83 / $76.95 / $338.32
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.16 / $48.71 / $78.95
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$65.84 / $79.19 / $124.35
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$64.86 / $80.31 / $151.35
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$61.04 / $71.45 / $84.95
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.31 / $48.68 / $72.36
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.55 / $70.55 / $70.55