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Utah 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
$2,744.00 / $3,592.00 / $5,743.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$532.17 / $532.17 / $532.17
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$873.66 / $1,190.82 / $1,735.36
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,078.00 / $1,556.00 / $4,495.00