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South Dakota rates for HCPCS Q4221

Amnio Wrap2, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,961.00 / $1,961.00 / $1,961.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,961.00 / $1,961.00 / $1,961.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,736.00 / $2,736.00 / $3,420.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,052.00 / $2,072.52 / $2,565.00
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,961.00 / $3,314.09 / $3,413.51
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,961.00 / $1,961.00 / $6,720.00
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,332.37 / $2,416.80 / $2,615.23
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,332.37 / $2,353.19 / $2,416.80
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,146.00 / $2,146.00 / $2,146.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,961.00 / $1,961.00 / $2,157.10
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,961.00 / $1,961.00 / $1,961.00
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,961.00 / $1,961.00 / $1,961.00