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South Dakota rates for HCPCS 15155

Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$696.01 / $766.77 / $766.77
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$606.66 / $696.01 / $766.77
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,454.51 / $1,792.71 / $2,240.89
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$871.48 / $1,172.50 / $1,845.11
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$719.62 / $1,811.39 / $5,854.96
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,223.00 / $1,809.79 / $3,929.20
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,345.66 / $1,668.74 / $2,182.58
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$781.60 / $1,215.28 / $1,554.50
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,143.00 / $3,143.00 / $3,143.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$707.40 / $1,424.11 / $2,215.28
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,310.30 / $1,603.10 / $1,743.10