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South Dakota rates for HCPCS C5277

Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,073.00 / $3,073.00 / $4,338.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$532.17 / $532.17 / $532.17
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$532.17 / $899.38 / $1,458.17
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$492.44 / $574.51 / $791.18
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$821.00 / $821.00 / $821.00