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South Dakota rates for HCPCS Q4124

OASIS ultra tri-layer wound matrix, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.00 / $2.00 / $15.14
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.00 / $2.00 / $3.02
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.59 / $18.20 / $204.17
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$9.33 / $9.33 / $11.48
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.45 / $4.17 / $15.14
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.45 / $2.45 / $5,370.32
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.95 / $2.95 / $10.96
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$18.20 / $169.82 / $204.17
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.88 / $12.88 / $12.88
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.59 / $29.51 / $141.25
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.51 / $2.51 / $2.51
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.51 / $2.51 / $2.51