go back

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
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,894.00 / $1,894.00 / $17,823.00
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,139.00 / $1,183.00 / $1,530.00
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
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,034.00 / $1,495.00 / $2,202.90