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Wisconsin rates for HCPCS C5272

Application of low cost skin substitute graft to trunk, arms, legs, 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
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,202.26 / $1,584.89 / $1,584.89
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$36.31 / $36.31 / $36.31
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$36.31 / $1,230.27 / $2,041.74
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$54.95 / $64.57 / $70.79
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,584.89 / $1,584.89 / $1,698.24