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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)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.94 / $26.94 / $26.94
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $29.93
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$22.70 / $47.10 / $58.88
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.66 / $27.90 / $30.05
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.09 / $44.09 / $71.48
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.09 / $26.09 / $133.71
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$27.90 / $45.42 / $65.08
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17.19 / $31.30 / $65.08
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.49 / $29.49 / $29.49
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $39.97
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.09 / $26.09 / $26.09
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.09 / $26.09 / $26.09