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South Dakota rates for HCPCS Q4191

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$655.29 / $655.29 / $655.29
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$655.29 / $655.29 / $655.29
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,715.75 / $1,715.75 / $2,144.69
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$957.90 / $967.48 / $1,197.38
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$730.43 / $1,234.43 / $1,750.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$730.43 / $730.43 / $5,727.50
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$876.52 / $1,321.21 / $2,113.71
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$582.48 / $876.52 / $2,113.71
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$717.12 / $717.12 / $717.12
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$655.29 / $655.29 / $720.83
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$730.43 / $730.43 / $730.43
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$730.43 / $730.43 / $730.43