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Arizona rates for HCPCS C5274

Application of low cost skin substitute graft to trunk, arms, legs, 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
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,170.00 / $2,640.00 / $5,506.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$188.00 / $188.00 / $188.00
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$294.10 / $1,143.18 / $1,810.96
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$37.70 / $48.39 / $81.83
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.00 / $934.00 / $2,041.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$716.00 / $1,535.00 / $2,175.00