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South Dakota rates for HCPCS L8020

Breast prosthesis, mastectomy form

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$228.62 / $228.62 / $228.62
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$223.16 / $228.62 / $235.14
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$108.00 / $170.64 / $314.52
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$306.92 / $316.50 / $395.63
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$201.77 / $296.05 / $1,269.54
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$95.93 / $180.98 / $313.61
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$261.51 / $314.52 / $462.08
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$257.58 / $318.93 / $601.04
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$200.84 / $235.14 / $279.50
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$94.06 / $160.16 / $272.94
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$280.20 / $280.20 / $280.20