go back

Utah 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
$2,870.00 / $3,294.00 / $4,387.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$188.00 / $188.00 / $188.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,078.00 / $1,556.00 / $4,495.00