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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
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$36.00 / $36.00 / $14,482.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$36.00 / $36.00 / $36.00
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,139.00 / $1,183.00 / $1,530.00
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$36.00 / $36.00 / $36.00
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$36.00 / $1,215.00 / $2,090.40
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$55.00 / $65.00 / $70.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$36.00 / $36.00 / $36.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,034.00 / $1,423.00 / $2,202.90