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South Dakota rates for HCPCS Q4190

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$112.20 / $112.20 / $112.20
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$112.20 / $112.20 / $123.03
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$169.82 / $323.59 / $407.38
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$181.97 / $181.97 / $223.87
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$128.82 / $218.78 / $831.76
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$128.82 / $128.82 / $1,202.26
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$154.88 / $154.88 / $213.80
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$169.82 / $169.82 / $204.17
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$831.76 / $831.76 / $831.76
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $263.03 / $812.83
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$112.20 / $112.20 / $112.20
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$112.20 / $112.20 / $112.20