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South Dakota rates for HCPCS 15769

Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$457.09 / $3,801.89 / $6,760.83
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$398.11 / $467.74 / $2,290.87
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$977.24 / $1,096.48 / $1,380.38
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$436.52 / $676.08 / $1,202.26
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$436.52 / $851.14 / $3,548.13
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,000.00 / $1,096.48 / $1,096.48
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,000.00 / $1,000.00 / $1,000.00
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$588.84 / $831.76 / $933.25
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,162.28 / $3,162.28 / $3,162.28
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$524.81 / $851.14 / $1,318.26
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$870.96 / $870.96 / $1,047.13