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South Dakota rates for HCPCS 15275

Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$88.43 / $156.46 / $4,086.02
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$83.79 / $136.29 / $208.40
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$198.50 / $266.20 / $457.72
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$123.45 / $225.56 / $407.19
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$162.69 / $353.43 / $3,593.56
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$157.59 / $285.73 / $495.35
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$203.78 / $294.64 / $425.15
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$153.97 / $229.57 / $307.92
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
$162.69 / $295.80 / $440.58
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$166.00 / $203.10 / $345.30