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South Dakota rates for HCPCS Q4105

Integra dermal regeneration template (DRT) or Integra Omnigraft dermal regeneration matrix, per sq cm (add-on, list separately in addition to primary procedure)

Facilitymedian $27 · 10th–90th $26–$470%50%10th90th$27Professionalmedian $26 · 10th–90th $26–$810%20%40%10th90th$26$20.0$50.0$100.0$200.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$25.70 / $25.70 / $81.28
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$25.70 / $25.70 / $44.67
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$22.91 / $46.77 / $169.82
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$23.44 / $29.51 / $29.51
Medica
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$26.30 / $43.65 / $75.86
Medica
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$23.44 / $26.30 / $134.90
Midlands
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$28.18 / $31.62 / $31.62
Midlands
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$22.91 / $169.82 / $204.17
Midlands
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$45.71 / $45.71 / $91.20
Sanford Health Plan
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$67.61 / $67.61 / $67.61
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$30.20 / $125.89 / $239.88
Wellmark
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$26.92 / $26.92 / $26.92
Wellmark
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$26.92 / $26.92 / $26.92