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Maine rates for HCPCS 15100

Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,659.59 / $5,754.40 / $5,754.40
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$588.84 / $891.25 / $1,862.09
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$724.44 / $1,023.29 / $1,412.54
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$776.25 / $1,071.52 / $1,949.84
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$812.83 / $1,148.15 / $1,778.28
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,659.59 / $1,659.59 / $5,754.40
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$588.84 / $954.99 / $2,137.96
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$812.83 / $1,122.02 / $1,737.80