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Wisconsin 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
$1,894.00 / $1,894.00 / $17,823.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$188.00 / $188.00 / $188.00
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
$188.00 / $188.00 / $188.00
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,100.00 / $1,449.00 / $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
$188.00 / $188.00 / $188.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,034.00 / $1,423.00 / $2,202.90