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South Dakota rates for HCPCS Q4150

AlloWrap DS or dry, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$77.62 / $77.62 / $77.62
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$77.62 / $77.62 / $85.11
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$117.49 / $144.54 / $204.17
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.11 / $85.11 / $104.71
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$85.11 / $144.54 / $169.82
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$81.28 / $85.11 / $380.19
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.00 / $102.33 / $102.33
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$169.82 / $169.82 / $204.17
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$77.62 / $120.23 / $173.78
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$77.62 / $77.62 / $77.62
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$77.62 / $77.62 / $77.62