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New Hampshire 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
$100.00 / $1,749.77 / $9,859.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$8.01 / $8.01 / $8.01
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$7,448.00 / $7,448.00 / $7,448.00
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,500.00 / $2,750.00 / $3,500.00