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Louisiana 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
$580.00 / $1,544.00 / $3,779.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$532.17 / $2,698.00 / $3,779.00
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$593.39 / $1,107.46 / $1,905.65
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$194.00 / $513.00 / $1,226.00