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New York 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
$1,575.60 / $4,386.00 / $10,152.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,544.00 / $6,593.00 / $10,686.00
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,691.00 / $3,382.00 / $4,707.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.02 / $0.02 / $0.03
CDPHP
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,071.00 / $2,071.00 / $6,213.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14,648.00 / $14,648.00 / $14,648.00
MVP Health Care
Facility/Professional
Facility
Modifier
Low / Median / High Price
$555.00 / $597.00 / $74,999.25
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$964.00 / $2,826.00 / $4,851.00