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South Dakota rates for HCPCS Q4256

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$735.05 / $735.05 / $735.05
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$735.05 / $735.05 / $735.05
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,312.50 / $1,312.50 / $1,640.63
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$952.69 / $962.21 / $1,190.85
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$813.21 / $1,374.32 / $2,220.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$813.21 / $813.21 / $8,436.00
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$975.86 / $1,459.25 / $2,529.37
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$975.86 / $975.86 / $1,122.03
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$804.39 / $804.39 / $804.39
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$735.05 / $735.05 / $808.56
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$813.21 / $813.21 / $813.21
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$813.21 / $813.21 / $813.21