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South Dakota rates for HCPCS Q4133

Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$138.74 / $138.74 / $138.74
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $140.12 / $208.11
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$186.05 / $204.52 / $232.56
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.94 / $163.63 / $173.67
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$136.18 / $230.14 / $272.36
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$136.18 / $136.18 / $1,448.75
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$163.41 / $180.38 / $208.13
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$161.19 / $163.63 / $192.29
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$151.83 / $151.83 / $151.83
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $138.74 / $152.61
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$136.18 / $136.18 / $136.18
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$136.18 / $136.18 / $136.18