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Missouri rates for HCPCS C5276

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; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,184.00 / $3,232.00 / $8,000.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$637.00 / $1,705.00 / $5,389.00
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $815.00 / $1,351.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$247.00 / $719.00 / $1,795.00