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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