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Montana rates for HCPCS 15115

Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$668.95 / $3,588.44 / $4,198.74
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$47,000.00 / $77,999.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,098.92 / $1,098.92 / $1,098.92
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$914.46 / $1,150.71 / $1,372.36
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$609.60 / $820.25 / $1,674.34
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$751.60 / $1,098.92 / $1,535.36
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,005.66 / $1,005.66 / $1,005.66
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,233.36 / $1,347.57 / $1,447.60