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Pennsylvania rates for HCPCS C5276

Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$806.00 / $2,505.00 / $8,017.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$764.00 / $1,541.00 / $7,197.00
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
$800.00 / $1,544.00 / $7,197.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$144.00 / $577.00 / $3,742.00