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Pennsylvania 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
$800.00 / $2,505.00 / $8,017.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$188.00 / $1,023.00 / $5,958.00
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$657.00 / $2,422.00 / $8,017.00
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$641.00 / $1,541.00 / $7,197.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$144.00 / $674.00 / $4,300.00