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GRAFTJACKET

South Dakota rates for HCPCS Q4107

GRAFTJACKET, per sq cm (add-on, list separately in addition to primary procedure)

Rates data updated July 2026.

Facilitymedian $100 · 10th–90th $91$1620%20%40%10th90th$100Professionalmedian $91 · 10th–90th $85$1380%20%40%10th90th$91$100.0$200.0$500.0

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
Setting
Facility
Modifier
Global
Typical Low
$81.28
Median
$100.00
Typical High
$100.00
Aetna
Setting
Professional
Modifier
Global
Typical Low
$81.28
Median
$87.10
Typical High
$100.00
Cigna
Setting
Facility
Modifier
Global
Typical Low
$123.03
Median
$154.88
Typical High
$169.82
Cigna
Setting
Professional
Modifier
Global
Typical Low
$91.20
Median
$114.82
Typical High
$114.82
Medica
Setting
Facility
Modifier
Global
Typical Low
$93.33
Median
$134.90
Typical High
$169.82
Medica
Setting
Professional
Modifier
Global
Typical Low
$134.90
Median
$138.04
Typical High
$851.14
Midlands
Setting
Professional
Modifier
Global
Typical Low
$104.71
Median
$134.90
Typical High
$134.90
Midlands
Setting
Facility
Modifier
Global
Typical Low
$162.18
Median
$169.82
Typical High
$204.17
Midlands
Setting
Professional
Modifier
Global
Typical Low
$117.49
Median
$117.49
Typical High
$204.17
Sanford Health Plan
Setting
Professional
Modifier
Global
Typical Low
$85.11
Median
$85.11
Typical High
$85.11
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$239.88
Wellmark
Setting
Facility
Modifier
Global
Typical Low
$91.20
Median
$91.20
Typical High
$91.20
Wellmark
Setting
Professional
Modifier
Global
Typical Low
$91.20
Median
$91.20
Typical High
$91.20