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South Dakota rates for HCPCS 15220

Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$588.70 / $755.87 / $755.87
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$567.75 / $711.22 / $957.35
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,265.90 / $1,741.29 / $2,217.51
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$737.44 / $1,092.15 / $1,988.55
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$703.09 / $1,898.65 / $5,728.24
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,195.00 / $1,689.95 / $2,364.42
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,145.00 / $1,586.50 / $2,059.11
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$780.42 / $1,193.53 / $1,502.10
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
$835.41 / $1,518.92 / $2,150.19
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,093.90 / $1,338.40 / $1,684.40