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Washington 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
$2,064.40 / $6,470.00 / $22,024.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$188.00 / $188.00 / $312.00
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$37.70 / $37.70 / $70.39
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$644.92 / $1,110.00 / $1,110.00
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$79,999.20 / $79,999.20 / $79,999.20
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$140.00 / $588.00 / $5,793.00