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Wisconsin rates for HCPCS C5275

Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$27.58 / $1,968.94 / $14,482.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$27.58 / $27.58 / $649.01
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,139.00 / $2,479.00 / $4,441.52
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$27.58 / $27.58 / $27.58
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$27.58 / $1,239.00 / $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
$27.58 / $27.58 / $27.58
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,034.00 / $1,423.00 / $2,202.90