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; 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 | $882.00 | $3,612.00 | $7,500.00 | |
Aetna
| Professional | $2,444.00 | $3,684.00 | $6,245.00 | |
Medica
| Facility | $100.00 | $634.00 | $1,883.00 | |
United
| Facility | $100.00 | $610.00 | $1,883.00 |