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California 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
$1,733.13 / $5,812.00 / $17,013.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$188.00 / $188.00 / $6,795.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$8.01 / $8.01 / $8.01
Blue Shield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$77.09 / $79.00 / $91.00
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$120.00 / $120.00 / $393.93
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.00 / $60.00 / $60.00
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$188.00 / $188.00 / $199.28
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,800,000.00 / $2,250,000.00 / $2,400,000.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$587.00 / $1,572.00 / $5,830.00