| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Molina
| Professional | $30.20 | $30.20 | $30.20 | |
United
| Facility | $436.52 | $436.52 | $446.68 |
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 | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Molina
| Professional | $30.20 | $30.20 | $30.20 | |
United
| Facility | $436.52 | $436.52 | $446.68 |