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Wisconsin 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
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,202.26 / $1,584.89 / $1,584.89
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,096.48 / $1,445.44 / $2,089.30
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$54.95 / $64.57 / $70.79
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,584.89 / $1,584.89 / $1,698.24