go back

South Dakota rates for HCPCS C5274

Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, 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
$2,290.00 / $2,290.00 / $4,338.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$188.00 / $188.00 / $188.00
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.00 / $317.72 / $821.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$821.00 / $821.00 / $821.00