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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