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South Dakota rates for HCPCS 15121

Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$125.14 / $203.77 / $203.77
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$174.38 / $294.70 / $535.33
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$311.61 / $469.85 / $571.41
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$211.79 / $336.17 / $397.84
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$821.00 / $821.00 / $821.00