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Arizona rates for HCPCS C5277

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 greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,582.00 / $2,933.00 / $6,483.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$532.17 / $532.17 / $532.17
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$587.35 / $2,283.06 / $3,616.69
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$189.04 / $220.48 / $341.74
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$532.17 / $934.00 / $2,041.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$716.00 / $1,535.00 / $2,175.00