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South Dakota rates for HCPCS Q4197

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$70.70 / $70.70 / $70.70
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.70 / $70.70 / $71.40
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$129.65 / $129.65 / $162.06
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$74.93 / $75.67 / $93.66
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$71.04 / $120.06 / $194.65
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$71.04 / $71.04 / $453.26
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$85.24 / $94.44 / $169.13
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.24 / $88.24 / $214.18
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$77.36 / $77.36 / $77.36
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.70 / $70.70 / $77.77
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$71.04 / $71.04 / $71.04
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$71.04 / $71.04 / $71.04