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Pennsylvania rates for HCPCS C5277

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 greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,020.00 / $3,077.00 / $8,017.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$532.17 / $1,426.00 / $5,958.00
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$954.00 / $3,389.00 / $8,017.00
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$934.00 / $1,659.00 / $7,197.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$144.00 / $674.00 / $4,300.00