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 | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $714.00 | $3,714.00 | $11,624.00 | |
Aetna
| Professional | $188.00 | $188.00 | $188.00 | |
Cigna
| Facility | $323.00 | $323.00 | $323.00 | |
United
| Facility | $366.00 | $1,950.00 | $4,970.00 | |
Wellpoint
| Professional | $16.00 | $16.00 | $16.00 |