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South Dakota rates for HCPCS Q4203

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,052.89 / $1,052.89 / $1,052.89
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,052.89 / $1,052.89 / $1,052.89
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$407.80 / $407.80 / $509.75
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.85 / $305.85 / $382.31
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$871.37 / $1,472.62 / $1,516.79
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$871.37 / $871.37 / $1,325.33
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$284.31 / $390.24 / $1,045.64
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$267.08 / $360.22 / $1,045.64
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,152.22 / $1,152.22 / $1,152.22
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,052.89 / $1,052.89 / $1,158.18
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$871.37 / $871.37 / $871.37
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$871.37 / $871.37 / $871.37