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South Dakota rates for HCPCS A2014

Omeza collagen matrix, per 100 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$153.75 / $153.75 / $153.75
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$130.69 / $153.75 / $153.75
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$88.31 / $130.69 / $130.69
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$153.75 / $213.08 / $259.83
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$108.91 / $128.13 / $270.75
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$72.31 / $88.31 / $139.75
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$7.13 / $72.31 / $88.31
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$130.69 / $130.69 / $130.69
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$128.13 / $128.13 / $140.94
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5.94 / $5.94 / $5.94
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.94 / $5.94 / $5.94