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South Dakota rates for HCPCS 15115

Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$655.69 / $773.64 / $773.64
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$580.72 / $680.91 / $773.64
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,421.20 / $1,837.12 / $2,296.40
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$834.20 / $1,161.44 / $2,046.05
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$804.95 / $1,817.18 / $6,003.04
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,397.00 / $1,783.10 / $2,364.42
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,421.20 / $1,783.10 / $2,154.58
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$861.81 / $1,347.26 / $1,584.91
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,000.00 / $2,000.00 / $2,000.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$866.31 / $1,566.15 / $2,211.58
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,255.09 / $1,535.70 / $1,777.20