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 | $3,776.00 | $5,866.00 | $16,467.00 | |
Aetna
| Professional | $3,776.00 | $3,776.00 | $9,062.00 | |
Medcost
| Facility | $188.00 | $188.00 | $188.00 | |
Molina
| Professional | $30.00 | $30.00 | $30.00 | |
United
| Facility | $225.00 | $1,221.00 | $3,585.00 |