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South Dakota rates for HCPCS Q4104

Integra bilayer matrix wound dressing (BMWD), per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$30.87 / $68.09 / $85.13
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.74 / $51.24 / $63.42
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$53.76 / $90.85 / $91.77
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $53.76 / $231.33
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$56.11 / $65.08 / $78.59
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.41 / $57.97 / $65.08
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$55.82 / $55.82 / $55.82
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $69.17
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$53.76 / $53.76 / $53.76
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.76 / $53.76 / $53.76